Sent:áááááááááááááááááááááááááááááááááááááááááá Wednesday, July 24, 2019 2:40 PM

Subject:áááááááááááááááááááááááááááááááááááá Transcript for Event: 4082423


Good morning everybody. Call the meeting to order. We are now in order P Rick and welcome members of the Council participants and visitors we have around the room and you will get to introduce yourselves but we have some really wonderful new members Greg Alexander Peter Christine Raul Chacon George Kerwin and Mondo and that fast but they will talk about themselves for a minute in a second in housekeeping note these are very important. So if you need transportation somewhere the train station or airport sign up for lunch before lunch at the desk so people can organize taxis for is always to sit outside they have to be called all new members this is important you have to meet at the beginning of the lunch break to have your picture taken and I can tell you this is a good thing the picture that was taken of me when I joined was probably the most best picture ever. It makes me look deceptively young and vital and I promise you you want them to do that and you can request a JPEG and use it on your publicity. If I left it up I would look like a haggard academic depressed ready for end-of-life and so also if you'd like to make a public comment if anybody in the room wants to make a public comment, at 11:45 AM let the registration desk know the cafeteria is across the hall and I always tell people that is the Korean noodle guys there rice bowl guide and you definitely want to go to him but last time it was the other Guy the sushi Ramen Guy so if you really want the best you have to run and it is quite good I was alarmed I heard the sushi guide might not be there and break your heart. Other good guys there and gals definitely period now we will introduce ourselves some rules you have to press the little light on your microphone to speak and when you are not turn it off so we don't have feedback in idle chatter coming through and if you want to speak aside from going introducing yourself right now raise your card and I can keep track of who to call on before you introduce yourself I will say just one brief thing, this is actually a critical meeting. This is not something you are invited to because your import or because you know a lot it is because it was not you could actually help HR Q with the future direction and our friend Paul has to deal with the stakeholders who funds the agency and many of whom are not only with health researches research may not have up complete view of how art fits in with the future of healthcare and needs to have ideas that are compelling and so it is not try not to say the same old in talk to the sake of talking which I know you want to but be bold and even disruptive the agency needs to hear thinking that is honest and fresh and potentially catalytic so the agency doesn't have to fight the same old tired fight every year about why it existed why it is relevant and you have to help the fine why it is relevant and why is different and what it can do for the people of the United States so hope that's okay. Why do we go around don't we go around I don't have a good icebreaker but one thing that has been worrying me lately is the trend which is not evident in this room for people to go to business meetings or meetings like this without any type and I looked around to see a couple people without a time but I see more people with a tie and I don't think it's a gender specific issue I think I would love to hear how everyone feels. I was going to start with you and now I am not. [ Laughter ] and in a very brief thing say what you think about the idea that men should wear ties some of the most expensive suits I've seen in ALI custom bespoke are man whose fabrics drip off them like they would never recall no matter what they did and they are not wearing a type that I really want to know what you think and also if you don't mind where you work in who you are and a little bit about yourself and I have to tell you that I've read hollow berries the pedagogy of the present and I'm reading the wretched of the earth and beginning to understand who we really are in the perspective we bring is critically important so if you could encapsulate your complexes lived experience in a very small entry into who you are and where you come from and what your experiences that would be really helpful so we can display some of the diverse thinking that is in the room. Don't worry I'm not that radical. These guys really especially the pedagogy already profoundly opposed typing about teaching and think we are all teaching and learning and understanding each other is important so why don't we start with --

Hi, good morning I am Karen and a pediatrician by training and serve on the knack of representative of American health insurance plan and have a group that includes both working in health systems and working for payers designing and growing Medicaid primarily government product Managed Care in Medicaid interested building care models for special needs population and finally my current position is assisting Indiana University help in building a community health program that goes beyond the community benefit sort of perspective that has historically nonprofit has had I'm glad to be here.

About the tie?

I'm located in Indianapolis Indiana and three grown children and the last one recently ties, not part of my wardrobe. There's a little bit of sometimes Andy that it is much harder many more options to choose from in your dressing as a woman for business and self having so happy not coat and tie would be an advantage

Good morning, everyone I'm a new member of the committee and I want to satisfy our chairman and talk about ties first. I'm from Seattle and Seattle University is very relaxed and I don't see faculty very few wear ties and I married 30 years with my husband and never seen him wear a tie so my attitude is do whatever you feel like. Anyway again my name is enemy from University of Washington by training physical oceanographer and study Ocean circulation CIs and atmosphere and CIs fashion and -- events happened my dad who died of medical error I become a patient safety advocate and my main interest now is to bring patients perspective into healthcare to improve quality safety and transparency accountability so over the years I have been involved a lot with projects and faculty teaching at UW Team STEPPS and a big fan of Team STEPPS and also a member Washington State medical Board as member a member NQF Patient Safety committee state inspection advisory committee and have a very broad interest in trying to bring patients of perspective into this whole process so I'm honored to be here and thank you.

Good morning everybody Jerry President and CEO of a MJ and also what the tie question the critical question of the day. Born and raised in Southern California, but interestingly I was a family physician and practice in San Diego and also became a Medical Director so going to meetings at the Hospital and going to meetings for the physician group I were a group every single day in San Diego. And I came here to the Washington, DC area and work in office where we do business casual and I had to buy new clothes because I didn't have business casual close I wore a coat and tie every single day I still have it of course and in the Washington environment there are certain meetings that kill and tie are suited or suit is required and I feel in the middle I have my the coat and tie for the DC type meetings and mostly every day no tie. Even last week we had a barbecue at our office and it was shorts so it was fun. A MJ is a trade association we represent medical groups in health systems across the country, groups like leaving Clinic mail UW Christiana other groups in the room and we are here in DC because we are advocacy organization and advocate on their behalf with regards to the move to value but we also do more than that we do education, Quality Improvement and even have an analytics department where we collect electronic health record data from our medical groups with about 25 million longitudinal lives and we do analytics in support of helping our groups improve quality and reduce cost. And I think that's about it. Thank you.

Hello everyone Tina Hernandez from Samford University and I also was born and raised in California and coming from California ties are not a necessity so I don't want to make that decision for others because again my wardrobe does not consist of a time so I think --

Many men dressed for their significant others

[ Laughter ]

I guess it would be do we have to wear heels because I think for women can we come in Stamford we get emails flip flops are not for the meeting so maybe we could put that on the table so I'm a's associate at Stanford University and biomedical science and biomedical informatics and surgery and PHD by training, a lot of my work is at the intersection of health services research and informatics and I do a lot and done other a lot of work thinking about quality management and patient safety and given my overlapping interest we've been really recently thinking about how do we augment our ways of measuring quality and measuring quality and guideline adherence in the digital age so how do we leverage electronic healthcare records other digital data also spend a lot of my time focusing on patient centered outcomes and patient generated data and how to integrate that into thinking about value care and quality measurement we don't have a lot of ways to measure how value-based care and patient centered outcomes are incorporated into clinical decisions and clinical treatments and that with that I will pass it on.

Good morning, everyone by name is Robert group to and I am currently the Senior Vice President cheap medical and health officer at March of Dimes in Crystal city so go back to the tie question, we often tend to in this country think in a binary way I think I agree with most of my colleagues is that do what you want to do and I think it's up to the individual because we the setting matters into debatable matters in your choice matters and it's a choice question to me and a little about myself one of the most meaningful things that happened in my career was very early on when I helped launch the first post polio initiative in New Delhi in 1994 which led subsequently 20 years later to the elimination of the disease in a country at 1.3 billion people and then in United States am a practicing internist and have been in academia and my last position was serving two governors in West Virginia at the state health Commissioner and a population health level along with faculty positions so coming back to March of Dimes has been in some ways quite interesting for me to be able to unknowingly wear and was able to help a bit in influencing polio eradication and come back to the organization that actually helped fund the vaccine to begin with and now our focus on the health of moms and babies one of the private funder for prematurity research in the world as well as impacting the challenge of the maternal morbidity across the country.

If you don't mind to make a footnote for those who are not familiar with the history in the March of Dimes and predecessor foundation, really pivotal in the history of polio and the vaccine but most people don't know it was the first major organized charity in the United States just phenomenal what it did and when I was growing up we all had cards we could put dimes in and some were too young for that but the other thing about it was it was the first foundation organization to realize that indirect cost were really important and if you wanted yield to work or whatever to work on some aspect of polio you probably had to cover the electricity and the heat and all that kind of stuff before that you could not become I actually teach that the whole class on this and it's great to have you here. Founded by FDR.

Hello my name is Amando Robinson on the cheap transformation officer at Christiana care health system in Delaware and I'm a third generation Californian and happen to live in Delaware now and that may lead to my Thai issue when we get to the second I am a practicing internist that hostile health services researchers Associate Professor at city Kimball medical College and Jefferson University teach as well multiple different areas of clinical as well as health systems and my job is cheap transformation officer and I also him him since consumerism for the health system is really to navigate that interface around driving health system towards what the future's going to look like future care in the future of engagement the future of managing populations and innovation and transformation the way we define innovation is something new to us with a uncertain outcome, the chance of innovation is that you can that outcome could be a failure which is okay but you have to learn from that and the difference from transformation is you take that learning around innovation around implementation science and that's where you drive the across an enterprise is really a change management box as opposed to a generation of innovation function that's my role within the health system. Despite the fact that I spend a lot of time in innovation and spaces that are kind of ill-defined I very much a structure around what I wear actually so this is going on for a while I'm a hospitalist and I done overnight shifts and I have rules and when I don't wear scrubs before midnight and I don't come in with scrubs I don't wear scrubs until after midnight that will one in for ties, I wear a tie every day except weekends and meetings. [ Laughter ] outside of my home area that's the reason I am not wearing a tie because I'm not at home and not presenting and therefore I don't wear a tie. Very structured. [ Laughter ]

Sounds a little like you're rebelling against something but I don't know what it is. [ Laughter ]

I'm not sure I can follow that. [ Laughter ] CHIP con I will start the tie I am a tie believer, I think it does make a difference in terms of tone and attitude, ties versus not ties and third as fashion statement ties are really important for setting off the entire outfit so I believe that without ties you are not the same. I believe everyone in the table should wear suspenders also but that's my bias. It is not caught on and also I wear hats every day which I think are both a health statement as well as fashion statement but that has not caught on either. I am President and CEO Federation American hospitals have been for 18 years we represent 20% of the hospitals the investor on hospitals across the country, this is especially great honor for me to sit here today because in a sense for me in a small way it comes full circle. I spent many years earlier in my life working on the Hill and back in 1989 one of the things that I did with another fellow called Peter but Eddie and some may know him what draft the original authorization language for the agency that you are sitting here on the Council today and we had a different name than there was a rename and bumps in the road since them and I could tell some more stories about those bumps particularly about 1995 but I won't bore you with all of that but the agency has always meant a lot to me and it is a great honor to actually sit here today having been there at the very beginning. Second Justin obviously Federation we were a lot about financing and healthcare delivery hospitals one of my concentrations over the last many years has been quality and performance measurement, I've been very engaged at National Quality Forum on the Board at one point and currently sit as cochair of the coordinating committee of the measures application partnership and very engaged in quality measurement, at NQF@and work hard in support of NQF and I guess that's one of my other reasons for being here is that one of the main missions of the agency is very important to me personally as well as in my day job also and with that I am here.

[ Indiscernible - Participant too far from mic ]

Minas Barbara and I will my name is Barbara I will dispense with the Thai issue I frankly don't have a strong opinion about ties but I am married to someone who does and happily shares your view that the tie makes the outfit I find he has a very large collection and I will find him standing there every evening gazing at his collection and picking the right one and build his outfit around in the other thing I don't know how you feel about this Don as much as he is into ties he does not like he is a sports jacket kind of got any occasion I don't know what to make of this but that's my Thai story so I am the Executive Director of the Betsy which patient safety Massachusetts state government patient safety agency we are nonregulatory agency we do our role is around research and analysis we can be an expert panel and we have a number of activities very central to our work which seeks to engage the patient voice and safety and we actually engage patient representatives pretty much in everything we do all of our research projects and our expert panels where they are full-fledged experts because patients are the experts in their care. So I will share a factoid about me since Don was interested in our backgrounds and what drives us and without going to a lot I am that got my start in DC at the public defender service and mental health division way back in the day when Saint Elizabeth Hospital was a large federal mental institution and so that France I think probably in many ways shapes a lot of my thinking about a lot of what I do. And with that over to you.

I am Greg Alexander and I have a lot of ties and I decided not to wear one today. And I feel good about that decision but so. I was sponsored by the American Academy of nursing for this opportunity and I'm a researcher and associate at the University of the University of Missouri and art funding for a long time and KOA awardee and a couple by ARC eight and a see a study innovation study and Payment Model for avoidable hospitalizations and utilizing and focused on Health Information Exchange and safety and communication and I have another understudy looking at IT maturity long-term care and nursing home specifically and built a model staging model around IT and trying to create liquid is between quality measures and safety measures that are reported by long-term care to the quality measures I'm a nurse by training and I was always told early on in my career that technology would make a difference in helping me make decisions that would put me at the bedside in do all of these things and and in some cases it did in other cases it didn't and so I've always had a mission to try to understand exactly how IT does make a difference in the lives of clinicians and I wanted honor to be here and thank you.

Good morning I will start with the time my husband is a Professor and for 30 years he wore a tie to work every day and I've always traveled and I came home one Thursday and said you didn't go into school today because he had on a a flannel shirt and tennis shoes and he said oh yeah I did I thought I would change my image. [ Laughter ] I said I think you need to find a happy medium or go back to the original. So that's a Segway of who I am in my name is Beth Doherty and I'm from health system out of Lansing Michigan and at the Critical Access Hospitals as Merrill Clinton Hospital in St. John's Michigan work for the largest for-profit healthcare and work for the largest not-for-profit healthcare system in the nation. I've traveled nationally throughout my career and I am currently at a critical access Hospital I in Michigan help in Hospital Association for rural healthcare in the Michigan quality preclinical access Hospital in Michigan which one of the leaders for quality Critical Access Hospitals approach to serve on this Board. I am trying to make sure that we have inclusion for people in rural areas we raised our family in the area where the children all graduated in classes under 100 it is a very small farming community in our primary Hospital is the Critical Access Hospitals so rural is important to me and to our families across the nation who have rural healthcare.

I'm Peter and I have a tie problem, I still have ties from high school and can't get rid of them and I came late them and prefer to buy them secondhand you find some really great ties that way, I first learned to tie what I tie every morning which is a half Windsor at the Christopher Columbus Catholic high school for boys in Miami Florida where I grew up brother Kevin emeritus brother do not allow us to continue with algebra two until we could all tie a proper half Windsor and I would strongly recommend against people Windsor it will strangle you to death you don't want to do that but I half Windsor is nice and even on casual Fridays I wear a tie and I have to get away from that but it's something I'm working on and I figure at some point I will get there and seriously a little bit about me I am the President and CEO Region Institute applied research Institute in Indianapolis we are celebrating our 50th anniversary this year health services research informatics research and aging research are a main areas of focus increasingly implementation science in addition to that I'm associate Dean and Professor at the value school medicine and the Vice President for learning health systems at IU health where we are working to actually operationalize the concept of learning health systems and I'm in MD rheumatologist clinically although these days I mostly do research and administration I'm also currently the elected leader in chair of the Board of Directors for the American medical informatics Association and my research is largely in the area of infomatics electronic health records and how we leverage those for improving research and care and a little bit personally, beyond the tie problem, I'm originally from Florida and actually a first generation my parents are Cuban grew up in Miami and I'm a proud Cuban-American and I also am a lucky victim of the misdiagnosis problem that I know is a priority for age ARC AHRQ telling people at dinner I diagnosed myself with a very rare condition and thankfully got through it and survived it I had a caramel site, a year and a half ago removed for those that don't know what it is like a plaintiff during a break and went be surprised there's only about 1000 cases in the US per year it's a tough thing to find but it's the kind of thing it doesn't need to happen that kind of misdiagnosis and I am here because I am here in spite of our health system which is what we need to fix up very motivated to even more so than I was before to help with that an honor to be here. Thank you.

I'm Kathy Bradley and I will circle back to the tie question and boring things up front I'm associate Dean for research at the University of Colorado in Denver and the School of Public Health I'm also the Deputy Director of our cancer center and NCI conference designated comprehensive Cancer Center will oversee research programs or an economist by training, I serve on the Nashville Academy of medicine National cancer policy forum as well my area of research is along to streams one where merging different data sets cancer registries and claims data in medical EHRs in order to understand disparity in what's going on with treatment who got treatment and who didn't and why and try to disentangle that and the other one line of research is along the employment outcome the fact that treatment cancer treatment in particular what do we do when we diagnose early treated aggressively takes in understand that impact on lives beyond just the treatment episode. And to move her onto the tie issue I am a Virginia native so I grew up in a very structured kind of light very formal, father was very formal but more a club or a clip-on -- I don't know what to say about that something around his neck and had a clip-on and now I am Denver would sets a new bar really for casual kind of place and my partner there is a Denver native has to were fairly sense of suits in his job but in his mind the tie is the place to be creative but he also thinks Socks is a place to be creative so he puts together and he's an account let me add that so managed to put together an expensive suit with a ridiculous time with equally ridiculous socks and I think the effect is lost so I'm leaning toward the clip-on.

Hi everybody I'm George Kerwin couple things about ties I have one on and a dimension I'm surprised it hasn't been mentioned but from my perspective Christmas, birthdays, recognition would not exist if there were not ties in every one of my ties comes to me through gifting and so when I put on this type I know that it came from a specific person a specific year, and they have a meeting from that standpoint so that's important. Of course when you get gift they come with different quality and I've known different quality ties and those of you who wear ties know that Ernest makes the best time and they are quite expensive and they typically if you get one as a gift you hang it up and keep it there well my first Hermie's time I don't have their not that many people give me those type of gifts I decided I was going to wear that thing and one of my proudest possessions is an airman's time and actually does happen that's worn out is totally worn out so that is my life with ties. And I'm George Kerwin and I am from the upper Midwest along with a few other members of Mac and an interesting place to be in the delivery of healthcare services and probably at times we get into that characteristic of the upper Midwest but I am a businessperson by background, and a graduate degrees in business, a lot of experience in healthcare, I decided to join the health system at a young age undergraduate with a business degree because at the time there were not a lot of business applications within the delivery of healthcare it was a very clinically oriented type of offering two people not a lot of business practices and yet it was a business that I studied business like most others with people and systems and processes and finances and the need to communicate with customers and we had customers we didn't want to talk about at the time but we did have customers, and so I got in at an early age and have had an incredible career in applying those concepts to the delivery of healthcare services and of course today we all know that healthcare services are very very much dependent on those business practices that we all experience. That has been a great part of my background and I hope I can share with you. One other point about that issue is I have been identified here as retired with upper for would've said prefer retired is in the past and recently retired indicates that person hasn't quite a bit of experience over a long period of time and when I was in the process of retiring I was asked many times well what is your proudest accomplishment in your career here? And it was very clear to me what that was, the proudest accomplishment was being at the organization long enough to be able to put together the components and help deliver health delivery system that function well, the human components including the entire medical staff, the technical components, clinical technology as well as information technology, the use of information, the interaction that we have with the market we are in, with the people we are serving, to put together the components to be able to say when CMMI came out with the pioneer offering, that we think we have the components put together to succeed as a member of that pioneer offering and we did join that and we had considerable success and so that to me is a long period of time of putting together patiently the components that are required to deliver healthcare services to a population. That experience and accomplishment is what I have most offer to this group.

Rather than having our representatives of other agencies go through the same drill I am aware I have pretty much trashed the agenda but I think I'm going to at least tell her you are so Paul is representing CMMI CMS and Robin Wagner from CDC, and Kathy from the VA and Mike from NIH.

Barry is an academic hematologist at Rockefeller University and he has been interested in translational research and why translational research has been such a challenge in this country and he points out that basic scientist translational scientist clinical scientist really do come from different molds and emblematic of that is how they dress. And he showed I remember a slide where he shows a picture but the basic scientist look like so a basic scientist wears a T-shirt, and jeans to work and that's their normal attire. Clinical scientist dress like us and that part of the reason why they don't seem to interact as well as they should. So I think the question that you ask is an interesting one because in some respects it gets to the heart of how scientist from different spheres do and do not successfully communicate with each other and in that way enhance the progress of knowledge.

I do have a tie observation nobody has said here and I'm surprised. So ties have never been part of my wardrobe so I want to address my comment while the tie wears in the room and tie wears anywhere else and I am far more interested in what you do and say than what you wear and that's a message for today. So I don't notice your ties and I don't really care about your ties but I really do care about what you say and what you do so let's do something great today.

I will say thank you for that as a designated management official your I have tons of logistic never included a dress code question which will now be added and I want you to know that I was going to say the same thing we want you to come here if means share your ideas of means if a long day major more comfortable doing it without a type you do that and if you want to wear a type it's fine to and just share your ideas.

It occurs to me I didn't tell you anything about myself so I'm a cheap scientific officer emeritus at Institute childcare improvement and also have appointments at Harvard and Harvard School of Public Health and emeritus means that you are searching for relevance every day, because people look at you and say emeritus and I am wearing a tie and it's a squirrel time I have three ties with squirrels and I was standing up or anyone who finds an attractive tie with squirrels by it and I will reimburse you this one is from Jeffrey from the monarch free networking heard the story got me a tie and refused to take reimbursement but I will reimburse and the question is only half trivial and joking, I went to a meeting around sustainable development goals in Rwanda and there were ministers of health people representing many African countries and everybody was wearing a suit and everybody was wearing a type and I asked myself worded that come from and why are these people wearing a suit and tie and what does that mean about the postcolonial era and what does it mean about cultural influence globally so although it seemed like a fun question in my mind I am thinking why am I doing this but more poorly why has it become a global issue for people and next time we will talk about what happened with nylons so we don't happen agenda specificity and with that -- AHRQ has accomplished a lot in what you note the budget and blah, blah, blah and you can say what you want and I know you won't do that.

You already know my colleague over here working very hard to put this program together with having introduced quickly the AHRQ team and maybe -- [ Indiscernible] as a first generation immigrant American it's a great honor and privilege for me to be sitting here today and leading AHRQ it's a great agency and internal optimist and idealist and I believe that time has come where art can make a impact on in the country my background and expertise in the in of industry government and entrepreneurship so I bring to the table the discipline of having served two presidents into governors and understand policymaking processes and as an entrepreneur I know love the rapid cycle quick moving approaches to making change and transformation a transformation got so I like being here and not known life without a type -- a tie that I was wearing a three-piece suit with a tie and looked out of place. My father died because of medical air and arrow are and that's the reason why I'm excited to be here and think about no harm I believe in that and this is the finest job I've ever had and feel Pashley honored having said that Sir may I quickly say a few comments of where we are and spend the day

You are in charge

You are the chair

I am delegating

Good morning once again and thank you to all of you all the National Advisory Council members for joining us today and to do joining us online in the room we are leading healthcare experts here around the table with us for a timely discussion I also want to give a special thank you to our chair Dr. Goldman for the tremendous work and leadership that is demonstrated during his tenure we are excited to have him back for an additional year to serve in this role thank you Dr. Goldman and also want to recognize -- back

In my class in college the only way you can fail which at Harvard is almost impossible is to call me Doctor or Professor three times so dashing

Thank you Professor. [ Laughter ]

I want to recognize the new members joining us today for the first National Advisory Council meeting this year we have eight new members which means eight new perspectives to help inform arcs work for the future and I know we have a full day busy time schedule and I'll move fast and as my associate Director here Ginger McKay Schmidt online who will provide us an update of arts accomplishments and after that we will hear from a Chief Financial Officer Lucy Levine to provide a budget update around 9:00 when is 920 dashing -- I will start a discussion on past accomplishments where we are today and what entails and what is before us in the future and strategies. Then we will spend the rest of the day drilling down into more detail on one of arcs strategic initiatives focusing on advancing person centered care living with multiple conditions and looking forward to these discussions and the game thank you for joining us and I will turn it over to Ginger.

Ginger take it from here.

Good morning. Thank you go Paul for handing it to me good morning Don and the rest of the Council and I'm sorry I couldn't be with you in person today but I'm happy to take advantage of our meeting technology to speak with you by remote take a few minutes here at the beginning of your meeting to tell you about some of the highlights of our recent work over the past several months are cast continued our mission to improve the lives of patients by helping healthcare systems and professionals provide care that is high quality safe and of high value with this work as our foundation we are in a position to support the department specific policy priorities while continuing to strengthen and expand our expertise in health systems research practice improvement, and data and analytics. This work has led to many significant advancements and I'd like to highlight just a few representative accomplishments this morning. So Jamie if we could move to the next slide. First of all we want to be clear that supporting the Secretary's priority initiative is a major focus for AHRQ and the opioid crisis is one of the most prominent of those initiatives. As the federal research agency was responsible for focusing on healthcare Arik has contributed peer-reviewed research on a wide range of topics that describe and analyze aspects of the opioid crisis from the perspective of the nation's healthcare system the research comes from the work of our own staff and also from art supported grantees you see here some examples to demonstrate how broad this work is ranging from a study on how we free formulating opioids into abuse deterrent or extended release forms affects prescription drug abuse and a study understanding the effects of position networks has on opioid subscribing patterns to other studies exploring the relationship among race ethnicity social determinants and health attitudes on overall opioid use. Importantly, in addition to describing in understanding the opioid crisis within this country, AHRQs research efforts also provide instructive context by comparing our experience with that of other highly developed medically sophisticated nations. This JAMA opens article is an example of that describing a study that shows how our prescribing rates vastly exceed that of their British counterparts. In another example of arts participation in department priority initiatives AHRQs data resources and our analyses of them have been contributing steadily to the secretarial priority to address drug pricing issues. In recent months we drool on our unique medical expenditure panel survey or maps database to offer trends and analyses on factoids of the Drug Pricing Program including these examples highlighted in recent statistical briefs and findings reports. The figure on this slide comes from one of those data analyses showing that in 2016 people who had at least one outpatient prescription medication spent on average 31% more than in 2009. So also note that the it shows the brunt of the increase is building the total expenditure figures for the over 65 age group that is the top blue line compared with the redline which is the under 65. Also while the out-of-pocket cost which are the lower green and purple lines decreased during this period, in every year those out-of-pocket and total expenditures were higher for the over 65 age group. Apart from the secretarial priorities katana has spoke with you several times of the importance of the foundational areas of excellence that are how we do what we do. These three areas or competencies are research, practice improvement, and Dan and analytics. And to begin research in the overall federal health research AHRQs responsibility is health systems research with a focus on understanding and improving care. Here are a few recent examples that highlight the range and scope of our portfolio. Such as a recent article funded study showing that more than 80% of antibiotics prescribed for dental procedures aren't not necessary and another study that showed that accountable care organization or ACOs are more likely to use home visits to manage complex patients care successfully than non-ACOs. Also a study finding that rheumatic heart patience Hospital readmission list are highest in the two days immediately following discharge from the nursing home. In AHRQs work and practice improvement we build resources that help systems and professionals can use to adopt proven healthcare improvement practices. One example is take heart a new cardiac rehabilitation project we launched in April. This project is an interagency collaboration with CDC designed to help hospitals implement CDC's quality improvement program called the cardiac rehab change package. Heart addresses research showing that although cardiac rehab following certain types of cardiac events can reduce mortality morbidity and readmissions, fewer than one in five of the Americans who could benefit from this each year actually participate. Increasing participation could save tens of thousands of lives and hundreds of thousands of hospitalizations each year. Our take heart project is a three-year National initiative to support hospitals and health systems improve rates of cardiac rehabilitation use. A different kind of resource supporting practice improvement is AHRQs recently released Network of patient safety databases or in PSD and this new database allows us to document analyze and understand safety risk and harms as well as strategies to reduce medical air. The in PSD is the first public database on public patient safety events. It is a publicly available online resource that captures not identifiable information on safety events reported by patient safety organizations in AHRQs congressionally mandated PSO program. AHRQ will use these data to create resource tools for providers and others to learn about patient safety events and how to reduce patient safety risk and harm across healthcare settings nationally. AHRQ will also make analyses of patient safety events available to the public and will submit a report to Congress on effective strategies for reducing medical errors and increasing patient safety. In our third area of excellence while we at AHRQ strive to maintain data that are robust and accurate, we are aware that data alone are also not enough. Which is why we focus on data and analytics. By adding the analytics to how we think about and work with our data, we emphasize the capacity to use our data to help help decision-makers make the best possible policy decisions. Joel: Director of our center financing cost trends and codirector of the art data enterprise initiative said in a recent blog blog in love effective translation and analysis of today's members will we adequately identify and confront our most pressing healthcare challenges. One of the foundational steps in accomplishing this is to make our different data available in similar ways supported by similar tools and through a common portal we call this our data tool harmonization project. Over the past year members of AHRQs data enterprise initiative have accomplished a comprehensive analysis of our databases and data tools and a special emphasis on the needs and desires of our data users. At this point the project has completed technical specifications assessed different commercial off-the-shelf products and conducted prototype test and we will shortly be making the final decisions necessary to implement and launch a new common data portal and tools. These enhanced data analytics capabilities will ensure that federal state and local policymakers will have timely and accurate data and useful analyses to make informed healthcare decisions. Finally a review of our accomplishments would not be complete without a shout out to our grantees who are respected and invaluable partners in pursuing our mission. You've heard some of their work featured in a few of my earlier slides addressing arts broader goals and I also wanted to mention to new request for applications or RFA's which we think will help us tap into the creativity and inventiveness of the research field to help advance our mission and priority. The first of these of the partners enabling diagnostic excellence RFA is a $2 million program to use current data and innovative approaches to explore diagnostic patterns and outcomes. It is program will also identify the risk and protective factors associated with diagnostic safety and quality diagnostic errors, and the effect of diagnostic errors on safety cost expenditures and utilization. The other RFA is for a $10 million continuation of our successful patient safety learning labs program. Learning labs are places and networks where transdisciplinary teams can identify closely related threats to diagnostic or treatment efforts associated with a high burden of harm and cost. In the labs provide the environment and resources to devise innovative design and develop rapid prototyping. They can also put the promising prototypes through further develop test revised iterations with a goal of improving diagnosis and treatment. So these are just a few examples in review of our recent work and hope they have provided an opportunity for you to get a sense of how we are pursuing our mission and goals. I will turn you over now to Archie financial officer Lucy Levine who will tell you how we pay for this. Back thank you Ginger I appreciate it. I am Lucy Levine and both the Chief Financial Officer and budget officer and am happy to talk to a little bit about the budget which is my favorite part of my job. Especially when it is good. In our current year right now fiscal year 2019, our budget is $338 million in discretionary funds. This was a $4 million increase over the 2018 level and $82 million increase over the proposed 2019 presidents budget and importantly this appropriation maintained AHRQ as a separate agency. The 2019 President budget had proposed to consolidate AHRQ into the National institutes of health, as the National Institute for research on safety and quality lovingly known as an ERS K so that did not happen and we received a $4 million increase, to million of that increase was earmarked to the patient safety program for those diagnostic safety grants that Ginger mentioned, in addition to million dollars was given to the health service research data and dissemination portfolio for research on population health. So we are busy working away to spend every single penny of those funds by September 30. Let's talk the Saturn is the fiscal year 2020 President budget for AHRQ was once again proposed AHRQ to be part of NIH. They only continued within NIH specific programs the smaller subset, those include the patient safety program, the medical expenditure panel survey, the US preventive services task force at a lower level, the evidence-based practice Center program at 750,000, the H cup program at nine point 7 million, $42.9 million in both new and continuing investigator initiated grants, that is a 10 million decrease from our current level and 4.5 million in funding for opioid research. So what do they not continue? The Health Information Technology research portfolio and including new and continuing grants were ended, and $38.3 million in contracts related to the health services research data and dissemination portfolio, that means no quality indicators, no tax and grants and contracts no data analytics contract support, most importantly no dissemination and implementation. The population health grant that I talk to you about in the prior slide Argon. And are gone and 78 point that the re-reduction me research manage and support and staff related to programs that are ending would be eliminated. So that is the bad news but the good news is on the following slide and I'm trying to end on a happy note and we submitted the 2020 presidents budget Congress in February the house is given as their mark it is 358 million that is $20.2 million over the 19 level so is our largest proposed increase in more than a decade. The Senate has not yet provided their levels and what I can say is I don't expect it to reach the house Mark but it will not be the presidents budget level either. And in addition it's important to note the house does not consolidate AHRQ into NIH. That's it and I'm happy to answer any questions and to and Donna to and on a happy note


Usurp some of the time we can make up some but I think is a generous lunch period so you really have to rush out to get your -- go Paul could you give us an update in a bit about your vision for the future especially with this news that the house is supportive and may want to comment on whether the budget reconciliation under I don't understand the details but I understand it includes an increase in domestic spending as well as military spending and maybe that is good news also you can comment on that.

That's a territory I want to stay away from. My colleagues over there anyway that I take a few minutes. Thank you Don so much and once again welcome to all of you here to AHRQ L they could quickly go about conversation rather quickly and make it short. Notwithstanding, what AHRQ today Secretary Alex Cesar challenged us to think about how we can improve the health and well-being of all Americans in the future. So today we will engage in a conversation about increasing AHRQs impact and what the secretaries call to action and in mind I would like to share with you my vision for the agency's future and not only my vision, but also the vision shared by my colleagues at AHRQ but particularly our senior leadership team who have done a tremendous job in developing strategies to implement this vision. It is one that I hope all of you will inform and embrace as well. Some of the previous members have mentioned some of these ideas during the last meeting and I hope am hoping to continue to define these ideas you have. While there is so much to discuss, the focus of my presentation to be today will be on three things, first, I will expand on Ginger's remarks and reflect on a few of the great accomplishments AHRQ has made during the first 20 years, next I will talk about where we are right now as an agency and as a healthcare industry as a whole. In doing so I will discuss a few of the disruptors I see changing the nation's healthcare landscape and as it is today and finally I will share with you what I believe is the future of AHRQ. My goal is for everyone to feel proud of what AHRQ has accomplished, confident about the state of our agency today and excited about the impact we can have on the future of healthcare by preparing for 21st-century care for the digital age. With that in mind, I want to start by recognizing a very exciting milestone that AHRQ is celebrating this year marks the 20th anniversary of these establishment of our as an independent agency within the Department of Health and Human Services we are really excited about celebrating this milestone and indeed our 20th birthday is an occasion to celebrate to take a stock of where we are and to guide our work as we start to envision where we need to be in the future. Over the last 20 years AHRQ has awarded close to 4000 grants to over 3000 principal investigators are grants total more than $3 billion. In addition as you've heard from Lucy, Congress has recognized the impact of our investments and has provided in cases in our budget over the last two years our partnerships with researchers policymakers clinicians patients and other stakeholders have been vital to our success thanks to great collaboration with the healthcare community are calves become the premier funder of health systems research which has led to substantial improvements in the delivery of care in America. With such great accomplishments, under our belt, I want to recognize the super work of art both current and ark both current and former and by the way our accomplishments would not have been possible without the agency's previous directors starting with John Eisenberg who inspired so much of the work that many of the service researchers do today Clancy Rick and Andy Byman all matured in extended legacy that John established our investments in research have shown noteworthy impact in safety quality and value across healthcare sectors. And most notably, AHRQs funding led to the creation of several major life-saving programs are funded Doctor Peter and comprehensive unit based safety program with which to radically reduced infections in hospitals and saved thousands of lives in countless dollars. Additional art funding that helped expand the program to more than 1100 ICs nationwide in total initial efforts to reduce Hospital acquired infections helped prevent over 20,000 Hospital desk and saved over $7 billion in healthcare costs from 2014 to 2017. Our grants also established evaluated the first Clinic for the extension for community healthcare outcomes initiative known as project echo. This project led by Doctor Sanjiv at the University of New Mexico school of medicine not only help providers come back hepatitis C to tele-mentoring and tele-consultation but also AHRQs funding is supporting states to use the echo model for opiate addiction treatment as well and if successful this model will bring medication -assisted treatment to 20,000 Americans in need. And one final example of Arctic success the last 20 years our kids been a leader in driving value as well with our support of the back -- was able to create the reengineered discharge ToolKit commonly as the red ToolKit hospitals that adopted the patient focused approach saw a nearly one third reduction 30 day readmissions none of this work would be possible without the help and support of the researchers who provide the evidence-based to effect real change I salute them. Because their work as improved delivery of care and save lives. That is a true success of Org over the last 20 years and however we are at a crossroads everything about healthcare landscape has changed the way it is delivered, paid for regulated even talked about. Some of the changes have been have been sudden and all have been significant and now the changes accelerate like never before and I see six major drug disruptors impacting how healthcare will be delivered in the future. And as such the work of R2 and research R2 I see the aging of the population in terms of eldercare and the change in the way R2 R2 two fundamental ways in which care is delivered three I see the proliferation of networked medical devices and internal signs for the digitization of everything and five the volume velocity of data to our healthcare system and lastly we cannot forget this one new entrance in the delivery space the googles and Amazon's and even the start of ventures that are looking at how they can change the healthcare delivery systems the speed of change is breathtaking. So what do all these trends mean collectively to us here? future strategies and some we can anticipate where they will take us with others we don't really know and at this point have no idea what the outcomes will be however what we do know is that all of these trends are converging to the delivery of healthcare in digital age and we are witnessing a compelling need for rapid transformation into 21st-century care. Given this reality we had our two -- AHRQ have taken a step what do we need to do to position ourselves for the future and that's acquired looking at AHRQ in a new frame at this slide shows you at one end we have the NIH driving research and extremely important research agenda and to do a wonderful job life-saving work at CDC at the bottom we research public health and at FDA we have research for drug safety and efficacy but equally important ladies and gentlemen is the work we do at AHRQ which is research for care and I believe Kieran care are two sides of the same coin and science and research to discover cures as needed and science research and implementation to prove it's imperative let me talk about what care means we really are moving from the brick-and-mortar error of the 21st 20th century to the digital age of the 21st century so if you look at the Care Continuum for prevention to palliative care but what you are looking at is an estimated 275 million Americans pass through the Care Continuum each are and trillions of dollars on the delivery of healthcare services and in that continuum there's many unanswered questions being points in unmet needs that must be resolved to ensure safe high-value, high quality, whole person holistic care. For the American people. While we are happy with the progress we have made thus far we need to do a lot more and the solutions is more health systems research we need to discover new knowledge and provide needed evidence that optimizes quality safety and value of the care that patients receive. Since I began my work as Director of Arctic I have made it my Director of AHRQ -- across the healthcare industry meeting with patients researchers systems leaders and policymakers among many others like you. I have heard in addition to investigator research there is a need a compelling need for rapid cycle research for operation research targeted research transdisciplinary research applied research and most importantly digital health research as well. Yes learning has to evolve over time I see that and I see it from a process improvement perspective and we need process reengineering that improves efficiency and effectiveness of our services. We need to focus on a whole person 360 degree care not just worry about the data flowing into the system for the sake of big data but data that includes social determinants of health and changes that way clinicians practice we may not even thought of yet this is why AHRQ is focusing on supporting shift towards her health systems discovered evolve that utilize a process improvement inspected perspective given all the disruptors I've talked about our needs to focus on how we can use our competencies drive the greatest possible impact in the future with that in mind here are here is how we see the road why and what and how the core competencies really are rooted in health systems research practice improvement in data analytics and our Amos to help get so our name is to help is high quality safe and high-value is told upon them and at the end of the day our vision and goal is to improve the lives of patients. This slide basically talks about how we believe we can increase exponentially AHRQs in the future if we were together. What you see is at the very bottom our foundational work that's what the Congress expects us to do and we must deliver now today. But at the same time to position AHRQ for the future we need to see where the block will be and talk briefly about the digital age that's where the Buc will be in need to position ourselves with that in mind. So to innovate for the future looking at a core competencies there are three areas that I will talk about a little more dealing with misdiagnosis and analytics and to get there we need to increase our current capacity and build upon it. At the same time respond to the Secretary priorities with ginger talked about a few years ago Congress passed the 21st century Cures Act to bring us the cures of the 21st century and my belief is that the next frontier to bring to the American people 21st-century care. Think about it. To do this AHRQ is developing long-term strategies and three challenges that are front and center involving digital healthcare ecosystem. One improving care for Americans living with multiple chronic conditions, too, provided data analytics to policymakers to empower informed policymaking process and reducing diagnostics air, I believe concentrated attention on solving these three challenges together with the appropriate resources can have the greatest chance of delivering meaningful impact to Americans as mentioned the first of these challenges improving care for patients with multiple chronic conditions think about it more than 25% of Americans live with multiple chronic conditions that includes 80% of Medicare beneficiaries the need of people with MTC's do not align with the way care is delivered and care for these patients is fragmented leading to poor outcomes and increased cost we all know about that. A multifaceted initiative to catalyze the development of a sustainable system that delivers high value coordinated integrated whole person care would radically change the lives of people with MDC. We believe this system should be based on primary care and by doing so prevent and manage multiple chronic conditions and are stands ready today to make the system Arctic stands ready --

Health systems research practice improvement in data analytics and looking for doing a little different morbid deep dive later this morning and afternoon and this work will be led by my colleague Doctor Bierman there she is and she will leave the discussion shortly I believe over a five-year period we think Arctic can set the change date are Ken -- and health outcomes quality of life and patient and family experience with care able to reduce health expenditures for this population by a 21% we will save the nation $2 billion annually of course we won't be able to create this impact alone we are counting on you to join us on this journey I hope you will be willing to see yourselves not only as stakeholders but also as advocates to help us accomplish these goals. In the second goal is to improve data analytics capabilities for research policy analysis and improvement despite the explosion of data many policymakers today still make decisions based largely on expert opinion alone and rather than data evidence of predictive analytics just as healthcare has embraced the practice of evidence-based medicine in moving to create learning health systems I think we need transformation policymaking process as well policymakers lack access to timely data and analytics to make informed quality decisions we can't get to real-time decision-making informed processes by the best evidence available without an integrated data analytics and information platform to capture more of a holistic view of the healthcare system at large. AHRQ a current extensive background experience and expertise as well as our existing data infrastructure to add new data from public and private sources to spatter nation's capacity to provide timely answer to critical policy questions for starters AHRQ is prepared to develop enhance and integrate full data resources expand maps create a National Medicaid data analytic platform create a National small area social determinants of health platform and develop physician practice organization database while building each of these data sources has value we must be sure these data are integrated more easily available to researchers and entrepreneurs inaccessible to local state and federal policymakers. At the same time we must also focus on predictive analytics to address rapid cycle request from HHS Congress in states Arctic stands ready to make this happen. And finally our third goal is improving diagnosis. Today an estimated 12 million people a year are affected by diagnostic error with approximately 4 million of these people suffering serious harm and research suggest the cost of diagnostic error to the US healthcare system exceeds hundred billion dollars annually we think is possible to prevent 1 million diagnostic errors by the year 2025 and working together we know that we can put in place the initiative needed to achieve that goal and again doing so will mean using all of AHRQs core competencies in bringing her expertise to bear on finding and implementing solutions. Just as with NCC we need new research on barriers and interventions to improve diagnosis and healthcare and this will include developing and testing digital solutions including artificial intelligence and understanding workflow in all its components. To increase the impact of this work we should focus on initial research on the three largest areas of diagnostic errors cancer vascular conditions and infections. It is estimated that these areas account for more than half of all diagnostic errors and while awaiting new research evidence and insights we must ensure that health systems and professionals understand what is already known about improving diagnostic safety and we must disseminate the findings to our existing safety networks this must include large-scale implementation project to support frontline provider and patient to address the challenges associated with laboratory results follow-up and just as important by the way we must also turn an array of diagnostic data into actual information that patients and clinicians need for making important decisions about care. In the past AHRQ has successfully used centers of excellence to spur innovation and spread inside and practice improvement models we should again develop several diagnostic safety centers of excellence to support development and testing of novel approaches that make better use of data and help make those analytics and data solutions available to stakeholders. We should also find ways to measure and improve patient safety culture and explore development of a diagnostic safety culture survey. In conclusion I hope you will agree that there is an almost potential for improving healthcare quality safety and value by focusing our attention on improving care of automatically be with multiple chronic conditions providing data analytics to policymakers to impart informed decision-making and reducing diagnostic errors. AHRQ has bought the potential in a plan to deliver substantial impact in these areas. Today Arctic stands at a crossroads much like our healthcare system at large. We cannot stand afford to kick the can down the road in wait for someone else to solve our problems. To me challenges synonymous with opportunity and I hope I have reassured you about AHRQs patient healthcare ecosystem and I hope I've challenged you to look ahead and tackle the hard problems and I hope that you will leave here today recognizing that there is a bigger better and more work ahead and am excited to hear your feedback about these exciting strategies and initiatives and look forward to a more in-depth conversation as it relates to NCC and again thank you for your time and service to AHRQ and I will now turn it over to Don. Who I am confident will do a great job moderating this next part of today's agenda thank you so much I appreciate your being here. [ Applause ]

Thank you, go Paul just before we continue I know that Chris joined us and did not get to introduce himself and Chris could you briefly tell us about you?

So I am Chris go show I am a nurse by training and Doctor to help systems management and one of those people who is always frustrated by the just position of Clinical Care leadership and research and how they just don't seem to come together. Early in my career I thought I can make that happen by shifting from a Clinical Care to leadership and I had made some success but not enough so I got a doctorate in started doing research and I had some success and not enough so I come back into operations and had some success but not enough and I recently have shifted back into doing research almost full-time with the focus on improving diagnosis and healthcare I was fortunate enough to set on the National Academy medicine panel that gives the initial work on improving healthcare diagnosis and passionate about that and leading a center that we started up at MedSTAR health which is where I'm currently employed and I am probably one of the most I'll say greatest advocates for AHRQ I was recipient with Peter without one of Pers patient safety challenge grants issued by AHRQ and add that work led to some of the work that is still be done across the country to reduce central associated bloodstream infections but my quite honestly my level with AHRQ started them and I bet a lot of personal funding since then from Arik but I am a voracious user and firm believer in going to Arctic first four tools and I teach in the School of Public Health at Hopkins to help in the patient safety net website and all the tools that we have as a place where we go the National strategy this is where I think the future of healthcare delivery lives and breathes and so I am honored and excited to be here in quite honestly I selfishly am here to learn but I will contribute whatever I can along the way and I have to tell you a tie story because I jumped in in the middle of this and I thought how weird why are we talking about ties and as I heard I tend to believe things firmly and I'm not afraid to approach people that I don't know well if I have ideas. I did that with Peter and challenged him to say is great that you could reduce blood infection that John help kids -- Hopkins stash the Keystone center of the tie story I was having flashbacks as people were talking takes me back to one of my very Pers roles as a senior executive in a Hospital. I was at my very first senior leadership retreat and our CEO had been in place for many years he was esteemed probably one of the best leaders I've ever seen in my lifetime and he wore starched white shirts and ties very formal person and our senior leader retreat for the first time ever said business casual and every other man on the senior leader team showed up without a time several had them in their pocket but they were not wearing ties and on the first break it was he told us to do this and he is sitting there in a tie how can this be? I thought well why do we ask him and tell him and they were like Mikey you do it and I did. And I went up in a safe and explained that people thought this was we were working leadership development and is going to be a new day and business casual was clear that people didn't need to wear ties and etc. yet he was wearing a tie and that confuse people and he turned red and said I have a retreat tonight after work you could take your tie off and put it back on and he was like oh I would feel naked and but you're the leader young and na´ve leader and he said well okay and he took his tie off and I said now you have to unbuttoned and he did a little and went back and was flush and read and think before saying that it made everyone promise not to tell his wife. Everyone has a tie story I think thank you Don I am truly honored to be here.

We are going to push the break if you don't mind for about 20 minutes so we can have some dialogue about go Paul's very interesting inspiring talk and I hope you have been taking notes I did have one clarification question because it went by I didn't get it all down you mentioned three data platforms that you are interested in and one was about social determinants and another was medicated and the third so important what are those

Let's go over all of them I think it is key

[ Indiscernible - Participant too far from mic ]

We started on some of this with the maps and had funding from the Robert Wood Johnson foundation to add what we call the medical organization survey to the MEP and we went back to the providers of care to the people participating in the medical expenditure survey to ask them about characteristics of the providers that they sought so we actually went to the physicians offices and asked them about what their organization is how many docs there are there once a practice, how the physicians are paid etc. so a set of information so that we could look at the characteristics of providers and how that has an impact on the care that is delivered so this is an area in federal data resources that is lacking these days there are no good provider surveys have information and particularly the linkage to the individuals are using the services and what their characteristics are and what they're using etc. so our proposal is to enhance those resources and expand that and again building off what we did in our medical organization survey.

Put up your tent

The social determinant different than County health rankings or other surveys what is that

We have a couple projects this is an area that people have talked about a lot lately with the recognition that a lot of health outcomes are not determined by medical care but by individuals characteristics and their environment and their past experiences etc.. We have a couple projects here one is sort of the internal one where we are trying to put together from available data information on different social determinants and then linking that to the information that we have now like the healthcare cost and utilization Project or the map survey etc. and creating a database with geographical linkage so people could link these data to other data sets if they wanted to then we have a large project with PCORI to develop a larger database which would be available again publicly to link to whatever databases they have so that is a multiyear project we are just getting underway right now.

And just a fair warning obviously this can be either virtuous cycle or a disruptive cycle in which we have great ideas and plans and the money is not forthcoming but if we are inspiring and visionary and describe exactly what it is we want to do it could be the funding will flow so hopefully and that is a critical thing for us to keep in mind there is no accomplishment or vision without some support so I am sure you know that far better than I and for the parking lot go Paula come back to this maybe I love that for part FDA and clearest exposition if you will have what you need think about mealymouthed detail things was clear and on the parking lot if we could come back perhaps to where the VA fits in where much of America's research and training is performed, where CMMI bits in which spans hundreds of millions of dollars on programs it tries to evaluate and where the data analytics and data platforms of the CDC fit in all of this and were the NIH portfolio fits in the czar in a way one could say all of that belongs in AHRQ maybe it does if it's around the care piece so if we could begin to think that through and come back to it in our afternoon session where we focus on the high need population that would be great so let's take why don't we go Peter

Thank you so there's so much to unpack and I will just say at the highest level I think it's very clear your strategy you laid out is very well informed and inspiring and I think you're on the right track I think the things you've identified our burning platforms are critically important so I want to endorse a lot of what you said I think you are on the right track when we talked about it and I want to pick on just one of the things you mentioned we were just talking about what is the social determinants based there's a lot of work as of pointed out happening in the space and yet the way we think about this and I think a lot of the way people think about this increasingly we are kind of at a place I was also determined is where were clinical data maybe 34 years ago where there still a lot of foundational work that needs to happen in the area sort of standards and how it is we are actually going to traffic in the data what meaning do they have they are obviously varying levels of granularity in terms of their connection to individuals and trafficking and that is not at all easy so while we see a lot of investment happening at the level of agencies at the level of states with departments of health, Medicaid agencies, health system certainly looking at vendors trying to figure out how they're going to manage and integrate these different platforms that traffic in social determinants etc. There is very little if any evidence to base any of these decisions on in terms of what should we be doing how should we be doing it what should we be purchasing how do we go about deploying these and using them for the intended effect so it's a great opportunity and I think squarely in the realm of and scope of what AHRQ can and should be funding to be thinking about some of the signs that needs to be done to really inform for instance what should we do in the realm of standards and how do we traffic in this information even in the creation of a resource and I applaud you for thinking about creating such a resource that will be one of many such resources states are developing them in individual health centers developing them and we are likely to all go off in different directions they create them in different ways that can't communicate with one a mother and we're sitting here five or 10 years from now taking how do we reconcile this and figure this out in I think now's a great time anticipating the need for this to say let's try to put some rationality around that and as a convener as a leader in the care space I think AHRQ is a great position to try to formulate some strategy around how we should be approaching this intersection of information and social information for the purposes of improving health in the system. There's a research agenda to be fleshed out. Expect somebody else had a temp card up --

I will add to that and I have a comment about an issue social determinants I think in the absence of this what's happening is insurers and payers are feeding the social need instead of the addressing the social determinants so it's almost become a need issue so provide you with for example overrides or rather addressing the fundamental challenges on the ground like homelessness and transportation deserts and maternity care deserts and there's a lot of value in developing foundational framework that actually addresses not just downstream but upstream the issues of the social determinants of health and would mention yes that one of the issues also is to link some of the work that the great work that happens with with the maps data there's a lot of debate about the Association plan or skinny plans and so perhaps some of the data effectiveness of these plans and insurers as well as thinking about how do we get ahead in the policy debate by getting the data that is needed helping to inform good policy and coverage and other things as well and help us to know because access is critical to good healthcare.

This is a great presentation to understand the vision and AHRQ is doing and one of my questions is that you talk about fundamental work which is practicing improvement and don't know what the agency thought and the vision on that as a budget cut and quality indicators works out quality indicators and dissemination information contract I just wondering talk about improved the practice in the rate without measuring without know how we do and implement and how to get indicators of quality and it seems there was a missing link and would help to get this in the remedy what would be a way to engage other stakeholders state or other National quality measure organizations to fill the gap, to connect the link to continue the quality measures and I saw that's very important to know how we doing and otherwise we don't know we have a greater research grant or a lot of good results analyze the data and try to implement it and don't know how what the result of the imminent patient how to do we improve the care so I felt that the whole issue about the improved care quality and I'm just [ Indiscernible]

I appreciate that. One of the things that stood out was stakeholder engagement and hoping that today we talked more about how our cologne cannot do everything we know that and we will have to have strong partnerships -- what I'm doing is long-term vision and plan and recognize efforts and build upon them and point is well taken and stakeholder engagement particularly in to consideration thank you.


A quick comment, I think in terms of the vision kind of tying into what you suggested Don about missing I'm curious if it's a marketing initiative or those of us who advocate but reaching out to community partners that we started to work with based on arts agenda setting and some research we are doing and what I'm finding is many community partners don't know where to go for information resources and I think there's a ton of information at ARC age so some of the work that's being done on creating culture of health if people contact me and say I don't know how to engage with hospitals or health systems where and how is the agenda for hospitals and health systems being sent and I think in that future vision idealizing that perhaps AHRQs primary stick primary stakeholders not just hostile health systems and providers but other community agencies that are involved in partnering with their local hospitals and health systems.

And point well taken me to think more broadly than just the way we are right now.

I wrote down for topics in this was in relationship to your ID around the 360 degree view of the healthcare system so I work and came from acute-care and beginning years in ICU and MedSurg and lots of acute-care experience and I transitioned out to community and home health and long-term care assisted living settings where I think there is a huge shift and focus now and I think in relationship to your ID about 360 degree view that and I applaud Arik you have a current callout for grants I think in our 18 that has long-term postacute care quality and those type of things and long-term care is often times overlooked and a big gap at meaningful use and stopped at the acute-care ambulatory care setting didn't take it out into the long-term postacute care environment and there's such a need for innovation and there such a need for enhancing advanced practice in raising the level of the ability of nurses to practice at their proper level and so I think those impact quality and so I think that along with just rural settings and long-term postacute care in rural settings where people are trying to stay in their home and trying to stay in place are important areas that provide a unique point of view around that 360 degree healthcare point of view. I think AHRQ is uniquely positioned and to understand relationship between Quality Improvement in those areas.

You will go to Kathy.

Just an observation I think on a lot of these data platforms and what's going on within the state and how we implement major policy we think about social determinants of health incredibly important but if you put that in the context of how does that statement implement Medicaid expansion and to have some opinion on whether they look at different levels of expanding in terms of a different level of threshold people that are covered this information is often missing from our data set of what interventions work and what policies work and how states approach different problems to be integrated to understand the environment the support systems that are there that influence how systems are structured, what's reimbursed and isn't who is covered and who is not and how that ultimately influences health outcomes within an area.

Point well taken and my colleagues want to have additional comments on the issue of social determinants?

I would just say it's one of the reasons we are proposing to expand the sample and the maps because right now MEPS state estimates we can make and you can think about ways to try to do studies that you don't need and that kind of thing

[ Captioners Transitioning ]


Is it to manage both high-risk patients and high-risk communities and also to do more partnerships, -- ownerships and community and public health. We actually got 50 applications. We got some really innovative, you know, the study session met a week ago and have really some innovative applications to that, so I am really, really excited. And to go back on kind of the standardization when how do you excited. And to go back on kind of the standardization when how do you measure it top we have another project internally funded through the PCOR Trust Fund to develop interoperable electronic Care Plans to be able to do patient-centered care in the community. Part of that is incorporating social determinants data and tried to build on the work other people are doing to try to come up with some on the work other people are doing to try to come up with some sense -- consensus on standard you can use for that purpose. Just wanted to add that.

Thank you, Eileen.

Karen, can you comment?

Thank you. I think another issue that working with social determinate data is going to raise concerns community organizations that will be partners. It's going to need to be capacity building within those community organizations in order for them to leverage and use the kind of platform that technology we're talking about. For the more going to raise a set of questions around standards. If you think about credentialing providers, if I am a healthcare organization referring to a community organization who I now have obligation to do more diligence or some type of credentialing process it raises a whole sort of set of issues related to the standard around community partners. It's going to need to be capacity building within those community organizations in order for them to leverage and use the kind of platform that technology we're talking about. For the more going to raise a set of questions around standards. If you think about credentialing providers, if I am a healthcare organization referring to a community organization who I now have obligation to do more diligence or some type of credentialing process it raises a whole sort of set of issues related to the standard around community organizations, and of course, I think I'll can anticipate the downstream implications of that might have for the sort of anticipate the downstream implications of that might have for the sort of a -- sort of organizations that may have fewer resources.

I will say Jerry so people on the phone will know who is speaking.

Thank you. Go, Paul, first of all. Thank of all. Thank you for your inspiring vision. I think our medical groups and Health Systems would wholeheartedly agree with those priorities.Two things that I just heard in your disruptor that I live every single day, and that is the issue of mergers, consolidations and entrance into the health space. I was please to hear about the medical organization survey, and a few data points, because what in your disruptor that I live every single day, and that is the issue of mergers, consolidations and entrance into the health space. I was please to hear about the medical organization survey, and a few data points, because what we believe at -- is a delivery system matters so that the context the context for practice improvement or the context, the organization for data analysis, we think is actually an important component that needs to be very will studied as part of the overall context. 10 years ago my members two-thirds were stand-alone independent medical groups owned by physicians. Now 80% our either owned or affiliated with hospital or for-profit entity. That is a dramatic dramatic shift in the entire organ place open up the newspaper or Internet every day to find to find out which of my members has bought another member. We are finding very much the whole healthcare system and the ecosystem has changed dramatically the amount of private equity in the marketplace is huge, buying practices that unprecedented rate. We think that's going to have a dramatic impact on how healthcare is delivered in this country, and I think, again, I would ask you to keep an eye on that, help inform healthcare policy makers, as well as those of us working in quality improvement what the impact is that positive or a negative factor.

Thank you, Jerry. Let's go to Tina then Peter and I will wrap it up so we can up so we can get to break because people are getting a little -- here.

I want to follow up on some of my colleagues comments regarding social determinants and -- comment about the lack of standards around these data. And right now everyone is trying to think about how they can they can incorporate social determinants in their analyses, and how we are going to include these in our AI AI technology machine learning, and still what we are doing is we're looking at certainly in the digital age, looking at historical data seeing what we can extract from these four social determinants of health. Really those that is going to be vital, how that information is recorded, how it was captured, and so this is introducing problems when were using sort of our machine learning and AI technologies in training our data on information on social determinants of Health. So, the ability to set standards and really provide the fundamental resources the ability to set standards and really provide the fundamental resources to understand what type of information do we want to collect, what are the standards for how we want to collect a report that data? What's the minimum information data? What's the minimum information that needs to go into these healthcare data sets regarding social determinants of health? I think it's a very big priority that AHRQ should have some stake in and said forward in a very dramatic way.

So noted.

Very will said. I wanted to put wanted to put another topic out there, perhaps, for further discussion and something I think naturally flows from your focus on the increasingly digital world that we live in, and that is and that is also a burning platform that I think where the puck is going in terms of where Health Systems continuously having to wrestle with how are they going to be able able to work into systems the emergence, the rapid emergence of AI, machine learning driven decision-support, and those kinds of tools. There is an immense, as we discussed, an immense amount of investment and activity ongoing in this space. Even as we have our broader data science agenda, generally across the Agency the way we need to think about these kinds of applications at the intersection of patients, Health Systems and how they are going to affect healthcare moving forward I of applications at the intersection of patients, Health Systems and how they are going to affect healthcare moving forward I think requires AHRQ to have a key role in this pick of in this pick of if it's very well within your agenda. I will put that there is there is something we should discuss further because right now, again, it's something of the wild West, again, again, billions of dollars being invested in the space bar very level of evidence in terms of what to space bar very level of evidence in terms of what to do.

[Indiscernible - low audio] for the conversation.

Thank, everybody. I just made a few observations based on what based on what I was hearing. I tend to do a little synthesis after we round the conversation. As I said I really like that idea of care is what AHRQ is interested in. I don't want to be to academic about the taxonomy, but I think we need to explain what we mean by care. So, when we start to get into social determinants and I heard people starting to talk about public health and you said, CDC and you said, CDC does public health. We do care. At this holistic care for the whole the whole person wherever they our, not the 5% of healthcare that account for health, but a bigger vision, I think you need to to be really clear about that because that establishes guardrails for your pitch, and for the main thing I would like you to think about is you have the competencies you have, or do you have to redefine the competencies you need depending on the vision of what you mean by care. I have the same feeling about the data analytics. There is so far exploration and little lack of precision about what is meant, and we know these new approaches, not so new new anymore data analytics, machine learning and networks and so forth will be important to Fellows who come in now wanting a Master's degree in artificial intelligence, not in health services and Ph type thing. What are the guardrails for AHRQ around that? Is this something you Partner? I don't believe the competencies exist right now in AHRQ to be players in machine learning and machine learning and AI? Maybe they do and I just don't know it. But, again, I would establish the guardrails and define what you ask for in do you bring on staff. And then, finally, the data platforms really our fantastic and data analytics are really i mportant. I would ask in-service to what Fort AHRQ? I know what it is in-service for the country, but for your agenda what is it in-service? That would immediately said to me, well, data analytics well well show gaps, need, show where we are learning something or whatever. That brings you into the you into the field of Implementation Science, and is AHRQ and Implementation Science engine? Is that is what is going to be funded and emphasized so you can close those gaps or is that somebody else's job? can close those gaps or is that somebody else's job? Within NIH funding more implementation in AHRQ does, what is that mean for the future for whose want to do that? Those are the things I heard and perhaps a little edgy comment but being clear with the boundaries around data and around the care is going to be really, really important going really important going forward.

Thank you, Don. This will require help we can get from NAC Members, as well as other partners to drill-down a little bit as well as other partners to drill-down a little bit more and further designed the strategies you are talking about. Thank you.

The Chair forgot to approve the minutes from the April meeting, so we need to approve the minutes. If anybody who was involved in that meeting and has any amendments or comments, please indicate. Seeing no tents rising, may I have a motion to approve the minutes. Thank you to -- . Anybody want to second? Jerry, you seconded it. So, all in favor of approving approving the minutes please say I.


Anyone Anyone who is a Ney.

That's wonderful. Please if you can come back in you can come back in 10 minutes we have been very eloquent but we are 10 minutes behind. 10 minutes, thank you.

[The event is on a break to reconvene a break to reconvene in 10 minutes.]

[Captioner Standing By]


Welcome back. Before I turn it over to Arlene to lead us through spirit discussion on people with complex healthcare needs secondary -- don't need Arlene to lead us through spirit discussion on people with complex healthcare needs secondary -- don't need to cite high need high-cost is problematic. Patients who have a lot of need. I think George, we cut you off. You had a quick comment to add-on the last discussion.

I don't want to belabor the discussion and cut into the agenda but I wanted to make a couple of comments about the track that we are going on, and clearly I agreed with Peter's comments that you m ade, and Karen, things that you said, and others that a lot of our work in the future is going to be dealing with the social determinants of health. And the comments I wanted to make is we have to recognize that when delivery systems get out there and to taking on that type of focus, it's messy. It isn't precise. There is going to be a lot of variation lot of variation in the ways that with organizations you got responses to RFP, and that is great. You are going to see a see a lot of variation. There is some fundamental concepts that we have to recognize, and some of the concepts are that while it is messy there is a wealth, a wealth of agencies and all of our communities and across the country that are working in areas that have a big impact on the social determinants. We don't have to re-create that. What we have to do is we have to figure out a way that delivery systems, AHRQ, and ourselves to plug into what already exists already exists in the communities that we are in. So, that's critical, lots of variation. It's going to be very imperfect and Bessie. I use the term messy -- and messy. I use the term messy. Operably we're going to have to pursue concepts we think might have some positive impact on the cost of care, the delivery of care but we are not really sure. And most importantly, we have to be satisfied with sitting at the table with other agencies that our doing work in education in the police departments, the fire department, and the school systems, and all of the other infrastructure within our communities. Keep in mind that it is messy and we have to be satisfied with taking a backseat.

I just want we have to be satisfied with taking a backseat.

I just want to make sure that we know Andy is on the phone who could not join us today. We will not make you go to the Thai exercise we did in the interest of time. Arlene, you're going to pose a bunch of questions. I am going to be the Timekeeper Facilitator, call on people, interrupt and whatever.

This is made.

This is because she's 52 years old and one of 100 million Americans living with multiple ongoing health problems. Me and her husband take care of her father and her husband. She works full-time and today has to leave early to catch the bus for a medical appointment. Maibach is tire. Patience with multiple chronic conditions have frequent healthcare appointments that can complicate an already busy schedule. The amount of information coming from many 52 years old and one of 100 million Americans living with multiple ongoing health problems. Me and her husband take care of her father and her husband. She works full-time and today has to leave early to catch the bus for a medical appointment. Maibach is tire. Patience with multiple chronic conditions have frequent healthcare appointments that can complicate an already busy schedule. The amount of information coming from many sources can be overwhelming, confusing, conflicting and in personal. Different clinicians offer different treatment plans and advice, and there's often little communication and there's often little communication and coordination between them. Clinicians do not have information and tools they need to best support people people with multiple chronic conditions. -- hard enough to deal with she also lives with depression, which comes with yet another appointment and another plan for treatment, adding to a life which is already complex enough. What if there were just One Care Plan created just for May and just May. One plan to treat her as a whole person rather than focusing on each of her separate conditions. A plan that is created by a care team with Maibach and her family easy-to-understand and agreed her family easy-to-understand and agreed upon by everyone. Like everyone, patients with multiple conditions the survey -- what would less confusion a better coordination between clinicians. Working together we can transform the healthcare system to the healthcare system to serve the whole person without complexity. It would take everyone clinicians, researchers, policymakers, patients and family working together to get it done.

We're not just talking about high need, high-cost patients. There's a whole continuum and I will talk about that a little bit later. I wanted to start because really, most people have multiple chronic conditions.about that a little bit later. I wanted to start because really, most people have multiple chronic I think Gopal Khanna some of these Stats. before but one in three Americans across a lifespan. It's at least four out of five five Medicare beneficiaries I think we are undercounting and really the way we deliver care does not need to be. It's fragmented, it's burdensome. It doesn't work for clinicians, patience, their families or anybody right now. On top of that low-income people and people with racial and ethnic minorities develop multiple chronic conditions at an earlier age and likely to have more. And so and likely to have more. And so they are having less access to care and may have more trouble navigating the system. There is really huge opportunities to improve care. And just think about what we are doing, are doing, we have a system that -- on diseases which we have learned to do to do quite well, the people with multiple chronic conditions account for 64% or two-thirds of all visits, 70% of conditions account for 64% or two-thirds of all visits, 70% of all inpatients, 83% of all prescriptions, 70% of all healthcare spending and 93% of Medicare spending. It really is a major challenge facing improving care delivery. I'm going to stop there and go back to the May video and just ask you, multiple chronic conditions honestly is a horrible word. We want to figure out how to talk about it, how to make it a sound bite, how to make a compelling and engaging. It's like anything else that when you see it you know what it is. I'm curious from the NAC Members, do you have examples like from your personal life of yourself, rents, families, who have dealt with this and in a system how it works?

My dad had [Indiscernible - low audio].

Thank you. My dad had COPD, and when your lung doesn't work will your heart does in, so we had that. I went to every doctor's office with him and I found out that early time with my dad advocate, I found his care is really not connected. I go to pulmonologist office and talk about how treating Emphysema -- the heart. I truly understand it's a great thing for the Agency to do to treat the person as a whole and the and the care team work together for healthcare from will take condition in a a whole person way.

That's my experience.

Thank you. Arlene, I have a personal family example but I think a bigger example is a message I got yesterday while I was here at orientation from my son-in-law who said, my assistant has a mother who is 83 years old who is seen two different caregivers, one for her COPD, one who is a regular doctor who says she has nodules on her lungs. They are telling our two different things. She is 83 years old. She doesn't know what to do. She asked her daughter. Her daughter doesn't know what to do. Her daughter asked years old. She doesn't know what to do. She asked her daughter. Her daughter doesn't know what to do. Her daughter asked me. My son-in-law is an attorney who works works in something totally unrelated healthcare but is also a registered nurse by background, and he didn't know what to do so he texted me. I haven't responded to him yet. I had to say I will get back to you. It's real. It's everywhere.

From my experience, I think one thing lacking in these discussions, and I think in health delivery caregiver side -- is that, is that people are generally, and I include myself.I could give a story just from this last weekend to live in a denial of conditions they have. If the conditions are particularly acute they can't deny it and get forced in, but I could describe what happened to my mother who died a little little over a year ago, and, frankly, she was almost 92 so she was going to die eventually, but she did not have to die the day she did. It was in the fault of the caregiver, although she had a terrible internist who did not provide the right care. But if she had gone to the doctor four four weeks before she did, you know, it would have been different. I think there are many people, and I think partly it's the systems intimidating the systems time-consuming, in the systems not welcoming to questions and inquiries. And people don't want to make of themselves as being sick, but it's very difficult to me. To be honest, so, I wasn't here at dinner last night because on Sunday morning I was a maniac with my pillow time and I ended up collapsing. I could tell the whole story. So, I spent spent Sunday and Monday in the hospital, and I'm fine. I am here, and I had every test in the every test in the book. I can tell you even, I, who is not pretty familiar with all of this stuff it was not a great e xperience. I didn't feel comfortable. I didn't feel informed. And like I was asking questions and stuff and the night in the hospital was horrible. Even though it was a very nice hospital. Everybody was very nice to me. I think the systemsEven though it was a very nice hospital. Everybody was very nice to me. I think the systems not designed to be people friendly. I don't know about this population health stuff and all of this, but it's not a people friendly system generally, even if you have caregivers that are caring. I this population health stuff and all of this, but it's not a people friendly system generally, even if you have caregivers that are caring. I don't know what else to say about that. Barbara?

So, I think we probably all have personal stories, but I wanted to share a little bit of research that mostly finished in Massachusetts based on the survey, started with the survey of bypass and household in Massachusetts reaching out to general population tried to identify experience recently. That we did a recon survey of that group and asked questions, including kind of open narrative questions starting with, so you have experienced medical error, what happened? And also asking them about what their perceptions of what the contribute he -- contributors were to these adverse events. There is some really interesting pieces that have emerged. First of all there's usually a cascading effect when you have a serious preventable -- event, it usually not just one thing. It's a whole cascading a whole cascading set of circumstances that results in harm. And the patients, and this is from the general population. We have the demographic i nformation. I can tell you it's very, very diverse park it doesn't matter if you are a highly educated, very, very diverse park it doesn't matter if you are a highly educated, empower, to also Executive, or if you are at the other end at the other end of the spectrum, there basically taking the same set of observations, which is that there is sort of the lack of communication across the care team, even within an institution, not just even in just even in the care transitions across institutions. And then another really interesting theme expressed was I thought they all had symptoms for this, like they just assumed that healthcare providers have systems that allow them to communicate important information amongst themselves, and they can't believe it. That's what's coming through the narrative is, how could this be that in this day and age that there is such little coordination? And that this is what's causing not only a bad experience but it's resulting in harm.

How much time do we have?

We probably should move on.

It's a powerful narrative.

It's great. I'm reminded of my mother who had multiple

It's great. I'm reminded of my mother who had multiple conditions, was frail, and my brother who was an was an engineer came to visit during one of her many Hospital Admissions. He looked at me and goes, just makes no sense. This is just the system. You don't have to connect the parts. I think it's the same thing. Even though I am a geriatrician, very knowledge think it's the same thing. Even though I am a geriatrician, very knowledge of and into her care was near impossible to coordinate the care. It care. It affects all of us, yeah, so I will move on and hopefully we can hear more hear more the stories later. Just numbers that basically in terms of Readmissions, the first graph shows the percentage of people with multiple chronic conditions, so you you can see only 14% of Medicare beneficiaries have 0 or one condition. But 98% of Readmissions are with people with multiple conditions, and of the 14% of people who have six or more chronic conditions account for 70% of all Medicare Readmissions. And I would say that our disease focus was we have had huge steps in improving care in a whole lot of areas, beta-blockers after MI, but then time to hip fractures and bundles, but what happens is if you look at the recent readmission, people are not, even if you do well is if you look at the recent readmission, people are not, even if you do well recovering and -- admission, something else is going to go wrong and they are coming back for other things. You are in the things. You are in the hospital for Heart Failure, in bed for a few days, it week, go home and have a fallen have a hip fracture. Even though you got fracture. Even though you got all of the right care for your Heart Failure. It really is is a complicated problem. The other thing is cost. One-third of beneficiaries, you know, 14% of people that six or more chronic conditions are about half of Medicare spenders. I think you all know this. This illustrates that. My next slide shows of the common conditions how many people many people have multiple conditions, and this is a lot to look at. Even something simple like hypertension. Only 6% of people with hypertension only have one thing, and 23, one quarter of them have five or more. Even for common diseases and even if you go something like Heart Failure, people with heart failure have five or more chronic chronic conditions. It's interesting and I will tell you more later but we are you more later but we are doing a series of stakeholder interviews to get information to try to inform the MCC initiative. We were talking yesterday to -- whom many of you might know who is brilliant. Basically what he told us is, you know, we figured out how to take care of the diabetes or heart disease or whatever, but we haven't figured out how to take care of Janice or may. I think that is where AHRQ can contribute is how we put all of the pieces together. The other thing is this is Pandemic. We have rising numbers, rising prevalent numbers, rising prevalent numbers of chronic conditions. If you think about it, we really don't know how many. I think all of the numbers are underestimated, and I will tell you about that in the next in the next slide why, but this is one study that used Haynes data. They found 50% of the overall population -- elderly have chronic conditions. Why is there estimate so much higher than everybody else's? Because they included obesity as a chronic condition. It's really with really with our definitions, and in their study 93% of Medicare beneficiaries had multiple chronic conditions. But the other thing is it really does affect the life course, it's just not things for older adults. Geriatrician is my area of focus and interest but when -- gave us examples yesterday of where systems had worked, he gave examples with cystic fibrosis then have diabetes. It does affect the life course and it's something where I think AHRQ is unique in being able to take that life course approach. So, what are we talking about? I think definitions are key and a language we're talking about. Is it multiple chronic conditions? Multi- morbidity? Illness? Multi- morbidity is a term often used seen ominously with multiple chronic conditions, including those with more than one physical condition, more than one mental conditions, including those with more than one physical condition, more than one mental health diagnosis or both. I can say the disease count, the only disease that sometimes gets into the count is depression and other mental illnesses are not included in those counts. And others use a term multi- morbidity to include additional factors that contributed to the burden of illness. This is things like -- disease, functional impairment disabilities, syndromes such as frailty, social factors, homelessness, food insecurity. What were really talking about is how is the person experiencing their needs and their health that takes into account all of this? I have some questions next but I am going to skip ahead and skip ahead and show you a slide that I was going to show you later. People think automatically about high-cost, high need, and there hasn't been a lot of talk about invention a multi- morbidity. You think about it Rick we had this endemic because it's the same risk factor causing these multiple diseases, so I think there is an opportunity to step back, address the social determinants, work with Public Health to prevent multiple chronic conditions. So, what I conceptualize is three strata. I think later in the conversation we could talk about where AHRQ should focus, or where we could contribute, the, really, we need to prevent, you know, prevention intervention targeted at reducing the prevalence of common chronic risk factors with a particular focus on interventions to reduce likelihood of those at-risk. Those are the things people we know already particular focus on interventions to reduce likelihood of those at-risk. Those are the things people we know already have multiple risk factors smoking, sedentary, poor diet, et cetera, and it doesn't necessarily have to to be the health system that does it, but we need to figure out how to Partner Effectively to move a to move a little upstream and address invention of multiple chronic conditions. The next group of people are people maybe like Chip you are talking too. Like, that a little high blood pressure, too be some Type two Diabetes, a little arthritis in their knees. I'm fine. These are the people targeted as -- risk with just one incident or one event from being complex. What can we do to better integrate, manage, ordinate their care to keep them as healthy, active and independent as long as possible. The last group is high-risk, who I am sure you heard a lot about because that is where the focus have been high need, high-cost patients in and out of the the h ospital, consuming disproportionate resources. The bottom-line is if we don't move back a deal with people earlier on you will always be replenishing those high risks and you were not going to solve the problems. I'm going to go back now to the back a deal with people earlier on you will always be replenishing those high risks and you were not going to solve the problems. I'm going to go back now to the question. From your perspective, I will lay it all out and I will let you jump in with what you want for time. From your perspective what is the scope of the problem? How should we talk about this? If it's not MCC, what is the language we should use? How is this issue being addressed are talked about? Is it something you are constructing in your systems and constructing in your systems and organizations? And for you from your perspective, what are the key problems as it relates to people with multiple chronic conditions? -- Roboinson. A couple of things to point out as we tackle these issues, and we're thinking about it from kind of managing populations, we tackle these issues, and we're thinking about it from kind of managing populations, including at-risk in terms of financial risk.A couple of things, one, the healthcare delivery system is so ingrained in being designed for and by the healthcare delivery orders that that transformation to actually being designed around the needs of an individual person and not the disease, as you mention, Arlene, but around around the individual person, that's a big transformation. And so, part of how we have to think about that is how do you build the systems that are designed and aligned to actually care for individuals? Yes we throw in social determinants and you've got to think about bigger things but at a fundamental level, how are you designing your systems to actually care for and you've got to think about bigger things but at a fundamental level, how are you designing your systems to actually care for an individual? For example, in your example in the cartoon there, yes, they come in. Them to see cardiologist, -- and and maybe psychiatrist. Out you take the cancer care -- clinic and how do you build something around that around chronic disease around that around chronic disease copper example. The other challenge we are having a probably along the same lines is, given the volume of patients that we are dealing with here, the question of how do you scale your approach. Part of what we're trying to get to get out, if your talking about rising population, it can be 50% of our total population we are talking about multiple chronic illnesses. How do you leverage digital? How do you leverage artificial intelligence? How do you leverage a lot of innovations coming out to manage these kinds of populations? What does that even look like? How do you know how to approach it? How do you know where the evidence life? How do you know how to deliver the care ask that you turn up your providers to be comfortable with and even experts in leveraging these technologies? So it really is kind of to me a fundamental design of your tier delivery model and system question.

Thank you. Let's it can be 50% of our total population we are talking about multiple chronic illnesses. How do you leverage digital? How do you leverage artificial intelligence? How do you leverage a lot of innovations coming out to manage these kinds of populations? What does that even look like? How do you know how to approach it? How do you know where the evidence life? How do you know how to deliver the care ask that you turn up your providers to be comfortable with and even experts in leveraging goal. Jerry, Tina, kind of to me a fundamental design of your tier delivery model and system question.

Thank you. Let's goal. Jerry, Tina, and Greg.

I want to be but my esteemed colleague Jesse because I agree 100%. We survey the groups to look at how how they wanted us to use data assets to improve care, really fell into four domains, but they all lead together. One is total cost of care of care pick t he second one is practice efficiency, the third efficiency, the third is high-risk patient, and the fourth is quality and quality measurement. And what they told us is that they want to work together using using these benchmarks to help them figure out how to take care of these high-risk patients in a cost-effective way within their systems. That is the issues they are struggling with in order to move towards value and to move towards risk. I risk. I will make one other point. I would think, personal, -- medical group and health system priority list, number one, because, again, the Cost Application a practice efficiency. We'll make one of the comment as a primary care physician. This is also a contributor to burn a. Well we have primary care physicians 15 minute office visits without the resources, especially many of them working in small groups or small small groups or small practices without the resources of the Care Teams that are necessary to take care of these Comdata patients without the Social Workers of behavioral h ealth, pharmacists, and all of the other Care Teams that they are swamped and they are overwhelmed.

One thing I want to throw when there is we often talk about 50% of what the population is. I when there is we often talk about 50% of what the population is. I would think have us think about, because we have colleagues here from other agencies as well. What if May was a veteran? With the care be different for her? Some models exist and I don't think we test them a look at them and I way, and going back to that primary care provision of care, which them a look at them and I way, and going back to that primary care provision of care, which May may be worth looking at from that perspective. I think the more we have multiple chronic conditions as there is more value to understanding the return on investment of four at-risk population and rising risk population. If we do that, study that direct return investment I think we are going to be able to invest in that. What typically happens that going to be able to invest in that. What typically happens that -- commodity well study. We don't have good return investment; therefore, we do not invest into the at-risk and rising risk; therefore, and up spending most dollars on high-risk populations. There is a reason we do that what we're talking about. The reason for that is not made a really good we do that what we're talking about. The reason for that is not made a really good case for investing in the at-risk and rising risk, so that's one piece. The other is that population has to be served also, got to remember in culturally competent manner.That's the other aspect. A lot of times, May, I go back to that person back May may not understand because it's not being delivered in a way that she could understand. That's critical. The third thing I will mention is the scope which goes back. We really have to have those conversations. Doing it cardiologist for every time for every time somebody has hypertension? Do we need a psychiatrist? Really these are primary care problems that needs to be enhanced, and, again, invested in a way through primary care systems, which is not just primary care physicians but all of the other levels of care that need to happen in order to make that is not just primary care physicians but all of the other levels of care that need to happen in order to make that happen. Lastly, one way to look at this problem is through the lens of prescriptions. Because there are states that have 18 to 22 prescriptions per capita, per man, woman, child, infants in those states. I think we are in a situation where we are really happy as physicians or providers to write a prescription for the problem rather than to spend time because than to spend time because that is the not -- that is not the way we get reimbursed the value. I think one way to look to the length of how much prescribing occurs which actually then results in a lot of these other drug interactions and other complications as of how much prescribing occurs which actually then results in a lot of these other drug interactions and other complications as well.

So, I agree with my colleagues on to what has been said and I want to take it back one step, because when we talk about these patients with chronic conditions, certainly in the hospital we don't really know how to treat them. Why, because their excluded from clinical trials. We don't want to take it back one step, because when we talk about these patients with chronic conditions, certainly in the hospital we don't really know how to treat them. Why, because their excluded from clinical trials. We don't know which therapy works best when somebody has these multiple conditions. And still there's really some opportunities, I think, too develop sort of what are, what is the patient population? What works best? What did they want? How do they value care? If you have somebody that has diabetes, hypertension, they value care? If you have somebody that has diabetes, hypertension, but ulcers but OBs, how do you, what's the best care model? What is the best drugs the work with them? I think there's opportunity when you think about all of the Real-World What is the best drugs the work with them? I think there's opportunity when you think about all of the Real-World Evidence available when these patients have this information on these patients with on a conditions, chronic Poly-pharmacy, et cetera. We haven't had a research agenda that really leverages that information to focus on this population. I think it can be a key agenda item for us for us to think about.

I am going to jump in for a second there because that was my next slide. It's the second there because that was my next slide. It's the evidence free zone. We do have a guidelines, and when people are well and well and have single conditions or mild the guidelines apply a know what to do. Actually, I have to I have to credit Carolyn Brown. This is from work she's done with Mary to develop patient priority care. And on the other end of the spectrum we have people nearing end-of-life where you make the decision what applies, what we solve and what we should do. The vast majority people are in the middle in what we call the evidence free zone, because we don't these are the people excluded from trials, so there's a whole agenda for NIH on what is the clinical management and how to address this. But, yeah, there is a yeah, there is a whole delivery system problem in there. There's other people who chronic care model is the first model that they need to be proactive and it takes multiple moving parts to manage chronic disease, and there's other people. Mary Canetti and Carla Brown have developed -- and innovative approach. And-- used to be on NAC sitting their developed minimal disruptive care. We need to think about these models and how to implement them, scale them, and apply them to actually apply them to actually provide better care. I had to jump in there because I was like.

Go ahead.

I will be quick but my comments from centers of Medicare-Medicaid innovations we been letting for the last six years, and we have two more years to go. Part of that project was too successfully reduce avoidable hospital real -- readmissions in the community, particularly in nursing homes where people we're living in St. Louis. We been very successful at reducing those, and most of St. Louis. We been very successful at reducing those, and most of these people have multiple chronic conditions, and we have been tracking about somewhere between 1300 and 1400 people over six years and managing their care. And then there are really six points and some you mentioned, Arlene, that we think that what helped us reduce hospital readmissions and help people -- key people in the community was by just doing fundamental assessments that are evidence-based in providing resources so people know what those assessments are. And that helps them to detect earlier the illnesses that are happening, and early illness detection is really an important area of work. And it really is almost warning systems might be dose or other types of things into before. In those settings we put people in there that provide a higher level of care. They cost more, but, ultimately, when reducing the cost of the hospitalization, there receiving a better better quality of care, their able to stay there so we are shifting the cost shifting the cost a little bit. It's not cheaper exactly, although it does reduce the hospitalization by modeling best hospitalization by modeling best practices and access to best practice and evidence. And part of this and -- and I were talking earlier was talking about building stakeholder neck work within those in the five the five surrounding nursing homes and the five surrounding hospitals is absolutely critical for us to be able to share the care across those settings, create systems are droppable, and droppable, and build innovations, and to share the responsibility of the care for those 400 lives across those settings. And we focused on end-of-life care and medical decisions, and we focused on incentives and payments to assess risk. And not everybody wants to work to get payment. It's interesting what motivates people to actually build when they can for preventing h ospitalizations. Sometimes they don't want to, or they don't have or they don't have time too. So you could put systems in place but they don't always respond the way that you think they will. And will. And then the final thing and we found this feedback tool, helping people understand where they are competitively compared to other organizations and being able to talk about that among the stakeholders has been hugely helpful in helping them to adopt the risk management approaches to reducing hospitalizations and keeping people out in the c ommunity.

Arlene, how are we doing on t t ime?

We have to finish this session.

We were going to go to lunch at noon but then we come back. So, the rest of the day we were short lunch to 40 minutes.

Okay, let me -- .

We have these three people.

Why don't we listen -- here for the last three.

They can help me deal with something that has been troubling me. Listen to this, where proliferation a bundled payments that a bundled payments that our all-condition specific that clinicians, you're members are struggling to get paid for or penalized. Maybe if we could have some reflection on that as well. That's a big disconnect to be cognitive of.

George and Kathy?

[Indiscernible - low audio]

I will try to be brief. I was listening to this problem with multiple chronic conditions and I was thinking about and I was thinking about how AHRQ funded some of the first decision tools, really, for patients to decide whether to pursue lung treatment or not, single disease focus, but maybe given some of the comments Tina make these people are not part of a clinical trial. This is the place for machine learning, comp additional -- computational method to develop tools in a much more complex way rather than what we did in this early evolution of personal rather than what we did in this early evolution of personal decision-making, so that they can be targeted to physicians to aid them. What do I need to know about this patient? And if And if I take this treatment course what is the cascade effect of that for various probabilities? That is the place for these tools and computational methods, to better understand the probability of downstream outcome in a multiple comorbidities situation. Otherwise you do end up with primary care physicians with 15 minutes. You need to be able to walk in and look at the sheet, what do I need to know about about this patient. This treatment course is going to lead to this outcome of this cascade of this cascade effect. What is most likely to happen? To that mapped out, when I think of the technologies we developed in other areas, it's those -- to be able to ask the question and get these answers. We should be able to apply those to this situation as well.

Couple of comments about some things that we found to be very effective.One critical issue, we're talking here about a broad, everyone, you're dad is broad. When it comes write-down to -- systems become more narrow and we have more more defined population. Delivery systems with good Information Technology has defined population. And there are a lot of ways of segmenting those populations. You can segment populations by the chronic conditions that a patient has, but you can also segment the population by the care for that population, for that segment of the the population. In other words, we can segment our population patients in our system and in our region by employer. We can identify all of the patients through employer. We can segment the population by those that are coming to us through pioneer and NextGen cost CMS patients, et cetera. The reason that that is critical is that when you segment the population by payer source, you are segmenting population by an organization that can influence and Partner with you and Partner with you in overcoming the cost for that care. So, in other words, people within an employer group, the segment, there's a budget people in that group with table conditions, and we can identify them through that employer and can influence that population through that employer. In other words, delivered dire resources. I would agree with those who who have said, then what. You have this data and segment population, you know basically the quadrant that you laid out, Arlene pick you know where people are, and you've got very small percentage of the population consuming a lot of pick you know where people are, and you've got very small percentage of the population consuming a lot of the resources, a lot of the financial resources. And then identifying what can we do? What can we do to better manage that care and is certainly improve the patient's conditions but bring down the costs? The tie here is between segmenting of population, identifying those people and being able to track them will through Information T echnology, identifying where they spend the money? Where is the -- going? What can we do in the primary care clinic, specialty clinic? To help more efficiently manage that patient population. I am kind kind of shifting the discussion from kind of broad clinical situations to a more financially oriented situation.

Again, and then we have tonight he wants to say something on the phone.

Just briefly, with the care has really come down to in the hospital or clinic it's really down to the personal level, each individual person how the care is delivered. I want to say briefly from the consumer health perspective, often we hear is lack of coordinate care. It seems like it's a very u niversal. A lot of factors contribute to t hem. Communication among the Team, Team, Health Care Team, indication between the Team and the patient and family is, and also how the record is shared. The records, written record, electronic record sometimes on a Chair. Diagnosis or not even communicated with team members. Also what is the patient and family's perspective and this chronic management of how to prevent it down the road, and what they want to prioritize their care. I think sometimes their voices are missing in this type of management. And also the insurance claims, and you have like, NPSD example. You go to psychiatrist care, and you go to other type of care. And insurance whether covered or not covered sometimes makes obligated for the consumer to navigate to all of this. This is all very complex to many for care as a and this chronic management of how to prevent it down the road, and what they want to prioritize their care. I think sometimes their voices are missing in this type of management. And also the insurance claims, and you have like, NPSD example. You go to psychiatrist care, and you go to other type of care. And insurance whether covered or not covered sometimes makes obligated for the consumer to navigate to all of this. This is all very complex to many for care as a whole.

I am going to run to the the rest of my slides quickly. Sorry, hi, 1019. I am supposed to be be where you are.

Thanks, and tying back to Don's comment and I think more broadly how I think of how NAC can help coordinate the different activities. This relates to Doug's comment about final payment. Is another, I was recently involved in AHRQ group with evidence-based, evidence practice centers, and how do we make systematic [Indiscernible - low audio] useful. One of the key topics that came up as a priority was understanding the chronic disease and, specifically, bundled patients and [Indiscernible - low audio] bundled patients. That sort of highlights the evidence that people are interested in that and again in terms of time and in AHRQ and different pieces of work that AHRQ can build on the clearly -- identified in terms of what be priority was understanding the chronic disease and, specifically, bundled patients and [Indiscernible - low audio] bundled patients. That sort of highlights the evidence that people are interested in that and again in terms of time and in AHRQ and different pieces of work that AHRQ can build on the clearly -- identified in terms of what be focus for -- efforts. That's it.

I think this, and the issue the issue was just mentioned and you brought it up. I think payment is critical here, think payment is critical here, and what Don brought up. At the end of the day will be face day will be face as we really only have two s ervices, fee-for-service or [Indiscernible - low audio]. You can go on and on about all of these. At the end of the day if you examine closely fee-for-service is still at the base of all of those things. And you create the artifices that replicate bundling. But at the end of the day you are going to chase could tell because you have fee-for-service basic. If you really want to get really want to get at this, vaguely, from my point of view and not necessarily the point of view of my members would be everybody, Alan was right, everybody should be an HMOs. It's everybody should be on capitation, because you are going to have to the figure out how to figure out how to make all of this work under Fee for Service and stop lying to ourselves about it trying to invent all of these new things or -- capitation. That's really the only alternative and a little bit radical to say, but I think experimentation to me is very destructive to the system. We're not going to have ACOs [Indiscernible - low audio] because they don't work. They work with good systems a lready. You can do all of this stuff in fee-for-service. Anyway, that is my two cents worth.

We have been thinking about this for quite a while and AHRQ pulling this together, and we developed a division of where we of where we would like to see the healthcare system go. I think it touches on a lot of the conversation around the table, so we would like to see I think it touches on a lot of the conversation around the table, so we would like to see a sustainable healthcare system that delivers high value, coordinated, integrated, all of the buzzwords, patient-centered care, in Primary Care that optimize individual and population health by both preventing and effectively managing multiple chronic conditions. And I purposely well not show you to the end of some of of the things we are proposing because I want to get more open-ended ideas. So this is how I see multiple chronic conditions.


[Laughter] given it's really the line share what we do in health care. If you care. If you think about it we also have a blind man, everybody comes from their perspective. Cardiologist sees her one way and the other sees another way nobody is putting it together to say, who is, May? And help her get it. I was really happy, Joe, too hear you talk about primary care. I'm a Primary Care Doctor and practiced many, many years. I agree the way we organize care makes it impossible, agree the way we organize care makes it impossible, and that's -- develop and design systems that allow primary care doctors to adequately function and really be the home for coordinating care. I will go through a couple of different models, but a lot of people say the primary care is dead because care is dead because we are going to have the retail clinics. We are going to have to go online and see somebody. That's fine if you are healthy, what I would say that primary care really has a critical role in taking people who have multiple issues, whether it's physical, mental or social and need that help navigating the system, so we need to we need to redesign primary care to make it feasible to do that. What will that take? If you look at the shared with the pulls a primary care, which I'm sure you all know, I will read them out. -- a family center, continuous comprehensive and equitable, team-based and collaborative, coordinated integrated, accessible and high value. That's really the needs of people with multiple chronic conditions, and AHRQ did a lot of the foundational work on creating primary care, and it's not going to be one physician who does this. It's going to be a team integrated. You can see many of those, really that whole person does this. It's going to be a team integrated. You can see many of those, really that whole person orientation as central to primary care. Once you have multiple conditions, you need more than a home. It takes a village. You need the medical neighborhood, and I think we've had some conversations about this, but it sort of how do you integrate primary care on one side with community services and public health? We should reinvent the wheel. But we certainly can Partner and align our can Partner and align our efforts. On the other end, how do we integrate primary care with specialty care? Acute care? Post-acute as people transition o ut? Home and community-based services? So there's a real role of building a medical neighborhood around neighborhood around Patient-Centered Medical Home. But even that is not an option. I would just call this a health community, and I health community, and I think this is what people we're talking about about earlier things like housing, access to healthy food, and transportation. I don't think the medical system should reinvent the wheel, but and there's a lot a people working in the space, so how do we work effectively to really share services, and have people work on what their expertise is, but really, aim it all at improving the health of individuals and populations. And I sent a couple of background materials. I don't know that anybody has had a chance to look at them but one of the things I I said was a paper actually of -- and the Team and my center, evidence for -- we have published in January and Journal of internal medicine. We called this the care and learn model. Because we think, basically said these are the two functions of the the two functions of the health system.Primary is caring. There's a lot of research on doctor-patient communication, doctor-patient communication, shared decision making and cultural competence, how to care more in an effective way. And the other trend at where things are going into learning as kind of the Learning Health System, the move to evidence synthesis, inflammation and then generation for the practice. We put together a model. We did this specific but, briefly, it's basically starts with a situation or a problem. That could be a problem of an of an individual, a family, a community, but most of the time people are in their own community and neighborhoods. They are not in the health system most of the time. They come to us when they need h elp. Then all of the tools we have of evidence-based practice, we assess the problem. We use evidence to solve it. We organize the response and we don't organize as effectively as we could. We adapt to the needs adapt to the needs of the p erson. And then we produce evidence. Did it work? Did not work? That we can use that to evaluate what we are doing and break the cycle. We would write -- really like to see research that aligns caring and learning functions with health care delivery. This is my last slide. This is from David Gore, health sciences University. He develop something called Care Management plus, which is a way of rationalizing care for people who are complex, but I complex, but I just really like the image. At the first it's Mrs. -- and she has multiple specialists, and caregiver. These are her past which are tangled a confusing and nobody could follow them. If them. If you rationalize it pretty the primary care team in the center with the care manager you can clean that up and make a rational approach to delivering the care manager you can clean that up and make a rational approach to delivering care. I see we are coming on lunch, and this was going to be the last question that we discussed in this session but we could move it over into the next session. We have actually struggled or what we pulled together to post what we think we could develop a research agenda. I'm going to show that to you at the end for feedback but we would like to hear from you you first what kind of research tools, practice improvement strategy, data analytics are needed to achieve better outcomes? Maybe people can think about this, and then we come back I have a few more slides and we can have an open discussion.

So that's great. We will take a break probably not enough time to get into this now, but I do want to use the chairs prerogative to be now, but I do want to use the chairs prerogative to be provocative. Prerogative of the product does whatever I'm trying to say. You put up a slide that makes the assumption that primary care is the Medical Home, and one of the exercises I have been doing lately is saying, is saying, what if it weren't? You know why a camel has two hubs is because they pile more and more more baggage on the one of until the middle collapse and now the camel has two hubs. You just in that model put a lot of stuff on the Medical Home, and we have multiple -- multiple models and efforts to make the call home, CPC+ too make it reach out and promote with partners community health. I want us to think through, what if that think through, what if that weren't the model? What if that is wrong? What really set me up on this was when you quoted Paul and said, look at cystic fibrosis. Cystic fibrosis is exclusively run by cystic fibrosis Specialist sitting in academic medical centers around the country who collaborate, and fibrosis Specialist sitting in academic medical centers around the country who collaborate, and primary care place a minimal role in their care. They don't get any -- back sometimes because people forget they need -- and never see their primary care physician. We have too somehow reconcile this. It's not just the contact between the student you are in a Medical Home it specialists. There is something wrong with that assumption because we keep piling on it. Physicians are burned out. Jerry's members are up in flames with their burnout. So, I'm not going to say that is not where we are going to go but I would like to see people reflect on what is wrong with to go but I would like to see people reflect on what is wrong with that picture, okay, why is the elephant sitting in the the middle of the room not being recognized when it comes to primary care? With that I suggest lunch and come back to answer the question, which is an important question Arlene asked, but with a little bit of disruptive thinking and maybe a little bit of edge that would be great. Ultimately, if we tell AHRQ to do the predictable, but predictable turns out to be not the way to be not the way to go, they are going to end up in a right Rick we don't want that. I'm sorry. I hope that's okay. I did not prepare you for that. What why don't we have lunch. Why do we have 40 minute lunch. If you don't mind to remember to get your pictures taken Rick I just looked at my picture again. It is so so also captures me. So, please go and do that. Then get your Korean noodles.

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The winds of change are blowing can we reconvene? I can personally vouch for those of you following my food column that even though the Korean bowl Guy in sushi guide are apparently being renegotiated for the suppliers whatever they do here, the Peruvian chicken was absolutely amazing and was Gabriel Escobar was here to verify that and against all odds the compound meatballs were actually pretty tasty, the pork from some ethnicity don't remember what it was was okay a little bland but the cabbage was truly excellent and the whole thing weighed only $4.15 so how bad can that be? Once again my main motivation other than changing US healthcare for the better is to sample the cuisine. There was a curry dish but I did not try that have you tried that? Are not as they say my household kibitzing about food and Arlene we will handed back to you and I provoke the crowd a little bit before the break. I should add that what I really meant was primary care in which the position is in charge if we take away that constraint the position has nothing to do and is a bit player in whatever the at it be less provocative and so some more slides and questions

Welcome back what I want to say is this is coming on next month my fourth year at AHRQ and done several presentations to the NAC and wanted to tell you how important your input is so when I first started our Health Information Technology portfolio was scheduled for elimination and there was lots of questions why AHRQ should be in that space we do the same process we did stakeholder engagement and talk to people and thought about where we could make a big contribution and presented to the NAC at the NAC gave us great ideas and we settled down on three priority areas of patient reported outcomes population health management, and care coordination and integration and we made progress in all three. We also presented our evidence-based practice program which is really the gold standard for systematic reviews, but has traditionally served professional societies to produce guidelines and we said can this product be more available more useful to more different kinds of people like her to be useful to learn health systems and again we got great input from the NAC and have a learning health system panel which is really helping us modernize our whole EPC program and I am just really taking and appreciated all the comments I've heard and we will take this in and I want to let you know this is really does the input you give us really does inform our program and program development. So thank you. The question is why now? Why are I think this is the right time things have a real window of opportunity I think multiple and pending crisis in terms of healthcare delivery and cost in demographics the aging of the population, rising prevalence of chronic conditions multiple chronic conditions, people are trying to focus on how do we talk about structuring payment with incentives and penalties and how do you get them right so people end up getting the care they need, I think there is finally border recognition of the social determinants of health both those of us in the public health based I'm trying preventive medicine as well as geriatrics and internal medicine and trying to bridge population health and clinical medicine for decades and is excited to see that people have finally discovered the social determinants of health. I also think on the research side this is also the time for two fundamental reasons and one we have new capacities with information technology to help solve some of these problems and a host of different ways and the other if we have more newer research method we talked about Don mentioned implementation science but how do we actually do pragmatic trials, complex design and how do we really learned how to make real-world evidence so I think all of these things are coming together and it is a huge problem and there's a window if we are creative and can really get it right to really make a difference in kind of address the problem. This slide is from a paper from a colleague of mine Walter who is was the President of the Italian NIH and it was not the US the whole world is struggling with how to get this right and he made a table of what was 20th century healthcare versus a 21st century healthcare and I want to point something out in relation ship to the things we're talking about today with the system that was really doctor centered in moving the patient centered and thinking about what that really means and how we care a person and actually meet their needs and the past the patient was the passive compliant this is what the doctor recommends now we know we especially with chronic illness the patient has to be a coproducer of health and really partner and take ownership of improving their health. We know we moved from the Hospital to a health system and I'm not going to go through all of these but driven by finance witches shapes a lot of perverse ways we deliver care now driven by knowledge and I would argue that is not just the knowledge the evidence how to actually manage no specific conditions but analogies the patient and wives and community and just in the past challenges were met by growth and now challenges need to be met by transformation and I think if we are going to really address the problem of multiple chronic conditions we are going to have to transform healthcare how care is delivered and just we have a team working on this and we begun engaging stakeholders and the topics really seem to resonate and we are getting good feedback so we've held several ISNI sessions including at the Society of Journal of internal medicine and Academy health with our learning health system panel and with healthcare systems research Network and have gotten great feedback on different ways we could approach a problem and we begun a series of conversations with the diverse group of stakeholders Hospital administrators, foundation researchers we want to find out what is AHRQ's unique space where his work that's not going to get done if we don't do it we want to know what other people are doing and the stakeholder engagement is helping us understand AHRQs unique role and identifying the most important is to inform priority settings and really will explore opportunities for coordination and collaboration and one of the questions I have later is on who should be our partners and who should we reach out to and I know go Paul's very interested in hearing about how we can better engage with stakeholders and what we hear from them a lot is there is a huge need out there to tackle this in a huge interest from multiple different places. And so you heard from Lucy this morning our budget is modest, we have to be very creative but we I guess settle on this like about a year or so ago and already started building a portfolio to give us the pieces of this so I think that one of the things we funded was under our dissemination and implementation initiative, we are about to fund a series of grants to improve the management of unhealthy alcohol use in primary care and you can think about alcohol use as actually a bigger impact on the population and opioids and it's a comorbidity for so many diseases and it is hard for doctors in a 50 minute visit to start there's a lot of resistance but what we've learned actually we funded Catherine Bradley to this and doctors when they realize the reason they can make quality targets for blood pressure hemoglobin A1c because the patients are actually drinking too much get very excited about tackling that. We have a series of six grants and what they're doing is at the same time they are doing the implementation of trying to improve quality around this issue they are actually doing some really innovative studies about how you actually integrate behavioral health and primary care now you make this work and what are the models that will work to make this successful. We had the Academy for integrating behavioral health into primary care which is been around for quite a while but it's an incredible resource with tools we have that people don't know and we have developed a playbook for primary care practices on how to manage depression care and actually in the full will release a playbook on how to manage opioid abuse in primary care settings so that should be a valuable resource and they also have a compendium of resources on the website on managing opioid addiction. I mentioned earlier we are working to develop interoperable EPA or plant because part of the challenge in coordination and information sharing so any system you need to have a mechanism to get everybody on the same page to actually coordinate care. And then some work we are doing around -- we put that in the bucket of improving care coordination and integration and that we are trying to also do projects through an improving patient centeredness and mentioned earlier a population health funding announcement and I think that's going to be really exciting in terms of like can you pull this data together or figure out which of your diabetic patient are food insecure and what other resources in the community to refer them to to address that and then one of the things that we've it's in the process now of being tested we had a very successful challenge to develop patient reported outcomes and we developed EPI winner was PRISM and is being piloted now in MedSTAR and by the fall we will know whether it was useful or not and how it work and I think it's really exciting because really collecting quality-of-life functional status that when you have multiple conditions that's what you care about is how your functioning and to be able to get that information easily and track it is like a really critical piece of being able to improve care for this population. So I told you about the Academy for integrating behavioral health and primary care and I don't expect you to read all of this they developed a lexicon and I think this also came up in conversation earlier that you all have different language for the same things so we need to learn how to communicate use the right language and all get on the same page and then go Paul mentioned this earlier that this is really a time of disruption and a whole host of ways and in terms of care delivery and that could be a threat or it could be an opportunity and it's like well these things are happening it might be the time to really rethink how we organize and deliver care for people who are more complex. So finally what is AHRQ thinking and we developed a five-year multifaceted proposal initiative that draws on on AHRQs unique resources and competencies to really advance the care of multiple chronic conditions and I can give you an overarching three buckets of what we are thinking and again none of this is written in stone and we would like to hear from you but the first bucket is to do real-world research and develop implement evaluate scale and spread innovative approaches to care delivery and placing the person at the center of care can reduce unnecessary or harmful care improve health outcomes increase efficiency and produce practice generated evidence to show knowledge and continually improve care and how can we do some really innovative research to look at what is working now build on that and get models that are scalable and spreadable? The next part is to really leverage the use of infomatics and develop the use of new data-driven tools to enhance care coordination and delivery of whole person care and model that can be technology virtual visit mobile health active support made up and not have to run all over the place all the time to support care outside the office interoperable digital dashboards to support care management and AI was mentioned earlier but AI to identify optimal care for different constellations of multi-morbidity and probably using practice-based evidence to data to generate some of that and to pull this together with a nationwide dissemination and implementation using learning collaborative to support scale up and spread there's two things here so right now earlier Ginger mentioned really excited about that we are using the model that was developed for Hospital acquired infections to do the scale and spread cardiac rehab of course across the country cardiac rehab is a good example there's tons of evidence it reduces mortality and recurrent events by 30% only about 20% of people get it and there's huge disparity and we are partnered with the CDC to develop a Million Hearts campaign who developed the change package around how to do this and what's nice is we will have an intense learning collaborative of people who are really involved in the intervention but it is open anybody to participate. People could be learning even if they are not necessarily members of the specific we are getting the support and intervention and we think if we create a Network like this it could be an integrative way to take the research and then have a mechanism to accelerate its implementation and practice as we get it and that is kind of what we were thinking at the high-level and there's details under all of these for example shared decision-making is key in this and there's little pieces that we will have to develop in order to make this work and so why should we do this? While the impact is better help in this what we were able to do is release burden and we care about reducing growing on patient's caregivers clinicians improve patient experience health and function of status and provider experience is very frustrating for providers want to do it right because the system doesn't really work that well and but also like I think is a huge business case here when we did some sort of quick calculations and we calculated that reducing preventable hospitalization in 30 day Hospital readmissions by just 10% in this population would result in 83,000 fewer PD level hospitalizations and 97 fewer 30 day Hospital readmissions a year. By reducing use of the cute institutional care eliminating duplication of services and adverse events due to conflicting management just a 0.1% reduction in spending would prove care coordination would save $2 billion a year and thanks to the economist at our center they did some calculations on cost savings by eliminating waste and they said that waste is estimated to account for 20% of total health care expenditures so eliminating waste and failures and Care Coordination could save as much as $25-$40 billion a year so I think a small investment by AHRQ and getting the evidence and how to do this right could have a big benefit for the system and help move towards achieving value in healthcare delivery. So these are questions, are these the right areas of focus? Are there other high-impact areas we should be considering? What opportunities are there to leverage our own work through partnerships and who should we be partnering with and how? Are others doing similar work that we should align with our that we don't need to do that because somebody is taking it on already more than enough work for everybody, from your vantage point what would be the priority so we would like to know what we could be doing and how would you prioritize that in terms of given limited resources that would result in a most impact as a release to multiple chronic conditions and then how can we work together really to advance this agenda?

Your questions are there on the slides and that was a very item ambitious and broad agenda and I am sure that folks have reactions. Don't be shy. Robin?

Thank you I love that and as you think about going to the patient centered view, I'm wondering how you're going to operationalize that because right now the data collected by provider and pair and how are you going to create data that is similar individual has the information at the at the individual level and that maybe a research question you can't answer today but it seems to me that I mean we face the same problem we were analyzing grants at a particular agency because he wanted to know the trajectory of the researcher where we only have the plans and outcomes that one agency you really can't say the full impact of that researchers impact of getting funding from other places and so forth so you have a limited view unless you have all the data around that person.

I think there to answer to that question, I think one is yes we could really harness data to help us and inform us and make tools and make it easier to share information and track people and see how they are doing but I think medicine is about caring as a human touch to it and we need to figure out how to to integrate that one-on-one conversation and understanding somebody and then bringing all the evidence we have to develop the best possible you know kind of care plan for them.

CHIP you will start with you and circle back to Karen

Actually I'd like to start with the question really Arlene, I mean it all make sense to me in terms of the sort of applied big goals applied research and delivery and doing being a change agent so if you are going to try to do this and scale it to where you think it needs to be versus what you're going to have in your resources because you mentioned modest resources, I have a question, how much money would you need if you are really going to do it because I mean with all respect it so ambitious and with the current amount of money it is hard to visualize not that you will make in a mill incremental progress but basically you can only do so much what would it take if you are going to actually do it seriously?

So I think that's the central question. I think and go Paul encourages me and that's why this is big and I think we can make a lot of progress with a more modest amount of money and we actually mapped it out to statistic things we could be doing and for example in terms of we have a mechanism called our 18 that research and demonstration to get things work and they can't get you know further disseminated we could start people experimenting learning collaborative would be a very modest cost and if we could bring that together there's people are places that are getting this that people could share and accelerate knowledge sharing and partner with investigators to get the evidence about it, so for about I think for $15 million we could get a small start and what our dream initiative is like about $175 million over three years we could do a huge make a huge dent.

These are multiyear large initiatives and cannot forget the enormity of problems for us so the idea is not so much that what can we do with what little we have but the question is what we are willing to invest to take care of the big problem in the long run.

I mean so if you had $1 billion over three years not 175 million or something, I mean does that make how much I -- do you think you have the capacity to scale up if you actually have it?

Absolutely and AHRQ a small and we are actually one of the I think cost efficient agencies because we do a lot we are actually with a very modest budget and but clearly we designed all these initiatives like when we have specific things we can do under all these to be scalable. We could start small and do pieces, and we could clearly scale the more -- realistic about the environment we are living in it would be nice to be able -- something we could communicate how do we get support for doing this kind of work maybe that's a question for you.

So the CMS project I alluded to innovations work we have done about $32 million, with that kind of money over six years we have two years left we thought sought real concerns about sustainability about everything we put in place and sometimes you don't work with people that long and a normal job and we've been working with these people for a very long time and they believe in what we are doing and they exit strategy we have for them is a really hard thing to deal with I mean to think about how to make all these process improvements sustainable how are they going to continue to work with HIE and a lot of these places we work with and long-term care area have begun to form formalized stakeholder partnerships with hospitals that we didn't have when we started and those partnerships have begun to become that part of the project that's going to sustain it because those partnerships now they are working together in building these systems to manage these people that move across their systems and I think whenever you build these big projects like this and you start thinking about them, you have to start thinking about sustainability from the minute the grant starts getting written and that is a very hard thing to conceptualize because it evolves so much overtime.

I have a question also it's something we think about a lot in the lot of our recent planting want people to write how it's going to be sustainable that upfront then the question is I think there's two kinds of sustainability, one is sometimes you just need the resources to make the changes and wants the changes are made and institutionalized, they can be self-sustaining otherwise other times and more often it takes adequate resources to fund it and it's like the way we've allocated our healthcare dollars more to the tertiary advanced expensive care and a little on primary care and we keep asking Don your question on primary care we keep asking primary care to be more and more and save money when we've actually under invested in it for decades and I guess the question I have for you is, from the project you did which parts can sustain without additional resources in which parts? -- What resources you would need to sustain to keep this going after your funding from CMMI?

Some of the networking we've done hardware infrastructure we've done to implement to raise the level of accessibility of information is sustainable because it is implanted it is just basically getting to a point to where they are relying on more information when we started out of the 16 facilities we worked with, 15 had paper-based systems now 15 of the 16 have electronic health records so they have begun in the six years we've been working with them to completely rely on information in a different way and I don't see them changing back from that so you build the infrastructure and give them some support to help them move beyond -- to realize that vision into make -- to help them become reliant on the type of information you want them to use and then not only that then you begin to build a relationship with people out in the community. The problem with that is that we found is that is not that -- the people in the organizations themselves especially in the community, they don't have the resources to have a person dedicated to build those networks and you have to have somebody to enable that communication back and forth and connect people and once you get that connection going and have a reliant on the connection then they can share all sorts of things they had not realized before and then that becomes sustainable so what sort of a piece by piece thing, that helps build the networks. That shares and allowed you to provide the share and care in quality.

As it relates to partnership and collaboration, I see that there should be a collaboration model at least if not a partnership with the CDC as far as they have a lot of data based on a community health needs assessment and the directions of communities are going with their healthcare and what those different multiple chronic conditions are because that's how we are building our healthcare plans is based on the data we are receiving. The other is the patient centered collaborative model to Don's question how to mix it up a little bit instead of looking at traditional model we've had with primary care physicians being that model I would challenge to look at having a whole different model that would be new to our system and maybe not so much to rural areas but where we have model that has nursing taking the lead is that Patient Centered coordinating person. And then last is Patient Centered home joint commission has been doing certification for Patient Centered homes for probably five or 10 years now and so I think they have information maybe not data but information that would help build the database for Patient Centered homes and using the knowledge that they've gathered through the years they do both large practice Patient Centered homes as well as small practice Patient Centered homes and I think there's an opportunity there to build your database.

Great, I wanted to address the question that we've been talking about regarding one of the elements which is again the patient caregiver family centered area. I think what we are living through now and seen is more and more capability technological capability to be able to have solutions that not only enable families and caregivers to be able to better manage and communicate and enable communication with different providers but also not just have it be newly directional dataflow where you can imagine there might even exist some early versions of absent solutions where increasingly can pull data from health systems and be able to have that. Even as we continue to work on the issue of fundamentally changing the health system with all the different sort of components that aren't really well aligned to provide care for people multiple chronic conditions, we know that right now I think this goes back to your point of the families and caregivers really being the ones that in the pages themselves that have to coordinate this activity, I can imagine ways that AHRQ could enable and encourage innovation around solutions that help that level of communication even in the current environment, and because of APIs that are becoming increasingly required and capable and other kinds of standard approaches to interact with electronic health record systems and the like, even be able to not just do that separate from the system that the clinician you see but do it jointly so that you can actually perhaps start to move the innovation in activity to a more Patient Centered model through a number of mechanisms I'm not exactly sure which is the right when I mean it could be a competition it could be in our 18 learning collaborative maybe all the above but a deliberate strategy that takes advantage of the increasing capabilities we have I think it is timely.

I want to answer the one question. We are framing this up around the concept of advancing Patient Centered Care for people living with multiple chronic conditions so we are framing it around the percentage of people with different multiple chronic conditions and the reality is the overall cost that those corresponding percentages caught the system the overall spend, and obviously I think we all recognize that I'm not -- I recognize that behind those percentages are people are individuals who are suffering and confused and don't know where to go in dealing with uncoordinated care so behind that there is a whole human side of this issue of what we are talking but I think you tried to capture that with the framing topic what we are talking about, but to me the slide understanding the people behind the numbers, describes very clearly the relationship between the conditions of people and the risk they are at in the corresponding cost in the system and we have lived as we talked about earlier we've been in the service environment and as painful as the escalating cost of healthcare has been in to some degree as much as we feel ashamed and comparing ourselves to other countries, that the Forest Service system has been the way that we've been paid. That and the issue of bundling you know the issue of bundling only to deliver systems is a specific tract in putting together orthopedic cases and getting everybody on the same page and charging for that bundle but in reality what's happening is the federal government which you are part of and we are trying to get funding to support this work, the federal government but then all major insurance carriers who are providing insurance coverage for the employers another in the sense of major customer of this work, and either there's various kinds of insurance products, they are wanting those numbers to decrease and what they are saying to us in increasing percentage of our work, increasing percentage of our work, when I listed a couple months ago we had 35% of our revenue was coming through in this is a bad term but value-based payments and it's a bad term because we don't know what goes behind it and we are trying to define it in the industry is trying to wrestle with that but bottom line is carriers CMS is saying to us the delivery system if you do this this, and this in the case of CMS, if you can provide care for this defined population, at a rate that beats the trend in the rest of the country one construct then you will have we will share that benefit with you. Again this is predicated on knowing that behind all of this are people and I don't want to lose track of that. And there is tremendous activity going on the world is changing and there's no going back and it is evolving, it is started a chain with the Affordable Care Act down this track and also with the meaningful use legislation that incentivized provider systems to automate and then ultimately is going to decent devises from not having automated and that was clearly thought out to make sure that the delivery system as a whole had tools to evolve. So we are well down the path of evolution, the tools are beyond the incentivized position and most delivery systems don't have the tools or have the tools I should say, the information technology to manage individual patients, so we are as a delivery system we are in a position where we are experimenting with different ways of identifying our patient segmenting our patients identifying people who are at risk many times based on their spend and then individually system by system trying to figure out what can we do to lower that overall spend? What can we do and we are out there asking questions and we are at the point now where there are multiple systems pretty much in states coming together and sharing what we've learned and listening to this and not experienced the first meeting not dashing what I think is missing here an opportunity for AHRQ is these things are in place and the payers are the payers are moving us away from fee-for-service pretty rapidly. And from a percentage standpoint impacting bigger systems may be more than smaller systems and we experimented with some things and we've had some success so there are things for AHRQ to look at and what worked, what didn't work, and what would work in managing that and I think there's a huge opportunity for that. It would be hard to do this work if we were not automated, if we had not had a taste of this, we had started to move down this path, but we all have so we are shooting and not academics so we don't know other than the bottom line we don't know other than the financial impact, we don't know how that translates to the individual patient to the conditions we are dealing with, and there's a huge opportunity there.

What is your need what would help you? Kind of do what you are doing moving forward? Back what is the portfolio of initiatives that delivery systems have pursued that what is that portfolio of initiatives and what is working? We heard it once in one issue was in terms of value, it is not valuable for CMS to have patients readmitted. It's never been valuable it's valuable to the delivery system because we get paid for the extra admission but there's no payment for readmission so very rapidly delivery systems understood it's very straightforward and very straightforward for the readmissions coming from their coming from the totally unaligned skilled nursing facility and let's go up there and see what's going on and lo and behold what's going on out there is they are getting fee-for-service and they want to keep the patient as long as they can thus we start connecting so that is one example and maybe that would be a first example because it is so prevalent right now but what else is going on? What initiative like that are occurring

I'm hearing two things where AHRQ sits on his face in Don brought this up before in terms of we see ourselves almost like as a science partner just CMS we could do the research and the work to figure out what works and develop tools that could be generalizable across a system that can be used by a some these programs one of the things that we are doing that I didn't mention and actually change in the center mentioned that something called the chest program which is the center for excellence we have three across the country and according to center and they developed a database of the 626 health systems across the country and have 25 data elements and the three there's three academic centers that are all doing research on what are the predictors, how does health systems use evidence, how do they what are the factors that are associated with being the higher performing health system and those are like a rich database for learning and I'm glad you brought it up because I think what we will need is multilevel interventions and we need to align these and we need to intervene in the Clinic between the patient and the doctor and make sure that communication is right and we need to practice to have a team to support that we need the health system to work we have to intervene at the multiple levels and figure out how to align these levels and I think that's a big part of it and those are the ideas we want from you and I think the other thing I am hearing from you is we also need to learn much working but what's working that's what brought me into this I started out actually Director of ambulatory care at a big public Hospital in New York City that did half 1 million visits a year and I also directed the primary care and child medicine residency program and we were told many years ago we had to do Quality Improvement we had no clue what that was and the doctors we got together and we realized we saw a lot of uninsured people and we all got tired of seeing late stage breast cancer in our patient and a lot of people were immigrants didn't know about prevention, within one year we got mammogram screening rates that were better than the best HMOs by working with the community working with the team we didn't do it in a way that was reproducible that we could explain what works and that's what actually got me here so I think how can we capture the learning from people like you are getting it right and incorporate it I think that's a huge challenge and I think it's a huge opportunity.

I didn't put my tent up outgoing orders most relevant to what we just said so I know that behind all this is a great deal of detail and probably a great deal of clarity but some issues of clarity have been keyed up in my mind and the background for this is that I was the PI on the playbook better care for people with complex health needs which funded by six foundations not by the government. And we've been trying to accumulate all of the models that have been developed to address his population. And I was in charge of the evidence review. What I can tell you from that experience was that there must be 160 of them there's a whole lot of them posted. Very few of them had a strong level of evidence, very few and I was extremely liberal by what I meant by strong and very few had spread beyond the organization that first described them except for a few. None of them if my memory serves had equity as and I can tell of black people were dying at home and not being readmitted to the Hospital so the Hospital could save a few pennies it's almost none of them patients were Patient Centered they had the authentic voice of the people they serve. We could get anything from premier or Vivian or Anthem getting the four profit sector to give their stuff was virtually impossible and that's a three-year effort. So from that background this is a question I want to ask because I don't think I've heard several answers is AHRQ going to be the scientific partner for CMS CMMI demonstration projects and if so, how long will that evaluation take so I just got done reading the Strong Start evaluation which was really terrific by a contractor three years into the project and six months after it ended that nobody is paying any attention to cost hundreds of millions it was a very expensive evaluation very slow and methodical and to be conclusive it was a good evaluation impact what you have in mind being a true scientific partner in that weight do you want to run demonstration projects in which you have some ideas based on your harvesting that you now want to do a straight which is something CMMI seems to be doing now is that what you want to do or is it what you are suggesting towards which is find out what works, well that's opportunistic and jumps onboard. The problem is as I was describing in the playbook we don't really know what worked all we know is that people tried it and claimed it worked in whatever way they looked at it and they are stopped so quickly especially with technology telehealth ads and so forth it's almost evaluate using the traditional health services research methods so and finally is a holistic in terms of a whole model includes the care of the patients waiting described or increasing the fragmentation so looking for example at rehab for cardiac whatever it was that fantastic it's important but it's a fragment and doesn't really deal with the whole issue around the patient the way you described it so these are fundamental questions about how to orient the work and I am betting don't go to it now you probably have thought about these and have priorities and answers to them but without being able to articulate that to Congress, they will somebody will say I go to Bellon and Bell and has it done and it works and why are you just taking what Bellon doesn't spread it and the answer is because it's hard -- the Camden coalition I'm involved with project spread the Camden coalition they are trying first it was going to be ambitious Peterson foundation big ideas now talking about three places Arnie Milstein did exactly what was described looked at the attributes of high-performing practices versus those that weren't performing well against cost a real value and got those attributes and Peterson said well we will spread that because that's what Peterson thinks and they had spread anything yet so figuring out that what it is you want to do with real clarity so you can pitch it if I were Congressman sitting there and here in this I would want to know these answers to questions maybe not informed enough to ask those questions but I'll bet there's committees that are. And staffers who are and that's my two cents on this and now we can go around to [ Indiscernible]'s back

I'm interested in FAF report patient reported outcomes I think this is a huge learning opportunity for the healthcare system because of Patient/ Family consumers participate as sounding boards health system delivered in Claire -- care I'm wondering if agency would think about too active again more consumer grouping involved in a more some campaign about patient report outcome and get more Patient/ Family members involved because I know lots of people are interested and have lots of experience and want to tell. My question is I don't know much about it so my question is is there any metrics to measure using this patient report outcome I know there's a quality probably metric any safety signals be able to capture?

We could send out a link prism map that is a really short video that show what they did they used a tool developed by NIH called promise and we started with functional status as a use case because can you walk can you do your shopping can you do the things you want to do is like a key thing for people but they designed it in a way that you can get other measures in their and there's other things that people want a measure easy to adapt the app and we should share that with everybody but I would love to hear from you maybe not now but how we can reach out and partner with and engage consumer groups I think that's a great idea.

The value is part of this goal. Value the quality and safety of adverse events is [ Indiscernible] I would like to see capturing in their and other thing is as I point never done healthcare research in the basics science when we submit a proposal to NSF for review proposals NSF the agency always have criteria that you have to have a plan demonstrate you can disseminate it your research results you have to have a plan how you tell the public your results and how they impact and we score the proposal and wonder if agency you do have that also? I am learning all that. Thank you.

Mine will be short and as a Hospital system CEO said to me once we will not get reimbursed for readmission 30 days but nobody's stopping us from re-admitting on the 31st day real story. So I think as long as we keep chasing that system is not going to give us results things will adjust the healthcare system adjusts itself basically used time in the business model doesn't change in the key costs keep rising overall -- back add a comment tell the person you're talking to that we are closely watching 60 and 90 day readmissions as well.

Same thing exactly. So I think is not the matter of again catching the fish it's about teaching folks how to fish and I think when we look at in the number of chronic conditions it's remarkable appreciate the work that is going on this area and thinking about but to the comments that of been set I think we should get to very specific around what we are trying to get to, what conditions and how and perhaps I think when we are intentional about what we are trying to accomplish it is easier to fund those research in that area rather than asking for proposals and everything else their nice proposals and get hundreds and they are not scalable and I would be more intentional specific.

I just want to say that I think the timing is really a good thing for arc right now and if you put the comment in the way you propose this in the right way for example I think that what I've seen happening in our larger projects is when we are working with a lot of facilities and especially working with hospitals and nursing homes and other it's a living assisted living environments and assistive care is that hospitals are getting very smart about who are in the community as providing the best care. They are reaching out to these people because they know they can provide good care. What is going to happen I'm afraid and I'm fearful of this because I'm getting older, is that there's going to be even greater disparity between the continuum of care of people that are providing good care and people that are not and if you're not in an area where they provide good care, where there is a facility that provides good care, where will you go to? And what will happen because the people of multiple chronic conditions is not going to go away it will only get worse I think because there's older people getting older every day. And so having an awareness of those partnerships and how they are impacting quality and outcomes given the rural elegy of things or even the urban setting is really important and the timing of that is crucial right now I think and I don't think we know enough about the infrastructure of long-term care to be able to understand what some of those impacts are going what kind of disparities those impacts are going to have and that be another area you want to consider. Kathy? Back

I think the area of multiple chronic conditions is really important and a right area of focus but I think if you're going to be scientific partners we also have to think about how you're going to be communication partners as well. Because as scientist, we don't do a good job of communicating. We put out tons and tons of evidence but it is not adopted for a variety of reasons and I do think some of the partnerships that we have to consider our private industry places that do masterful communication. It's beyond just dissemination and implementation research but having a communication partner with the evidence that's generated the kind of scientific evidence that AHRQ is good at inputting the data systems together but how do you get it out in a way that's understandable, that is adoptable, and so that it has the impact and I think that's been a piece that's missing in terms of communicating the message and the success and kinds of things you are doing and if you're going to make and roads in this kind of very important costly area is to communicate partnership that has to exist as well and to have a plan for that so is not just great evidence and data and everyone kind of glazes over but is being able to get the message out in a way that's understood and adopted.

You know you raise a point that is what Corey tried to deal with is how do you translate and disseminate the findings from science so a patient and provider can have a sure decision which I think is really important and sorry didn't see you Barbara

Actually I put my signed out earlier because I didn't know we were going to go to this direction but I think it is an important direction and I had a more general question not just about the work but how AHRQ uses role in the dissemination and implementation piece because this is -- any issue that AHRQ is working on there's a research component and maybe resources development component and that seems to be -- really good model for doing this you are generating appropriate research and superb tools and you get down to how do you actually move this thing challenged age-old challenge mood into practice and curious how art back views it role in the implementation even if you recognize the importance of good communication and implementation because -- first part does tree falls in the Forest problem and how does the agency view the role partnering with others passing the torch?

We are past or the affordable care act to do dissemination and implementation and actually have a structured process open for public nominations and looked for things that can have a high impact whether strong evidence and a big gap in practice and we actually have the structured process of looking at the strength of the evidence and the feasibility of implementation and take heart cardiac rehab and a piece of it we try to structure it in a way that gets at the other thing and we are taught coordinator get out of the and looking at disparities and we have the evidence and that's the challenge we have the evidence for the so today we've had this to the Orient seven regional lab UFAS management and primary care and we were able to and rule 1500 small and medium-sized primary care practices across the country and I think what makes AHRQ different from CMS is that when we do these interventions for implementation, we also want to understand use it as an opportunity to understand what works to implement so we did a lot of practice capacity to change what is the effectiveness of practice system facilitation if you build capacity to do cardiovascular risk management does that translate into other topics so yes we have a huge portfolio around dissemination and implementation and we actually did the Nashville Academy did a thing odd different model for managing high needs patient but we start looking at the evidence we don't have enough right now to know what is really scalable and would work in a more generalizable way without a lot of additional resources so that when we kind of put out funding announcements to kind of learn and what we are doing with the alcohol is like we know this is a problem and know there's things you can do about this evidence-based intervention we don't know how to get that into practice efficiently so what we are trying to get you know the investigators is while they're improving care to really study what works to improve care so with everything for where you have the evidence to where you don't and I think we need to do both.

Quick comment and I'm a little overwhelmed right now I don't know what I think about much of anything. I've heard a lot of great things

That can't be true.

In that case, I keep going back to conversation that Jerry said before lunch and our reality of I will say burnout providers not just care practitioners but others in the field who are up here and care just as deeply as they ever did that the area more convinced than ever that they will not be able to deliver on the promise of medicine or nursing whatever with the system says as we have so I think in any of the frameworks or models that we introduce we have to keep that in mind and I think at someone who's done a lot of art scare large care collaboratives and echo hub during the first echo with some success in several others that issues we are poaching that way and I think the impressive attribute of that model is not the information we are conveying it is the opportunity for peers to communicate with each other it is the collaboration that's been lost by providers no matter practitioners in any way shape or form who are wedded to these things or to her production line so we give you the information that's on your laptop next patient next and somewhere AHRQ in the care piece of this we have to be careful not to lose sight of caring for the providers because we will have great evidence or no providers to deliver it.

I want to make one comment about a perspective on a question that I think I have not heard raised and that is, thinking about multiple chronic conditions do you want to study how patients implement in their own lives the treatment plans that we actually ask of them and increasingly we digitize not just social determinants but more importantly the patient and the person there is a risk if we are not linking to those data sets that the work will be done by the private sector and may introduce some additional some sort of harm and by virtue of the fact that again it is and that evidence free zone.

Georgia comment?

What we are seeing is this is a picture we have right now. It's basic and understandable. Behind the left column are people that to the left column are people and the left column and behind the right column are reasons for that spend and there are line items and nursing home thing might be one of those today might be going away in the future but there are specific improvements in the way that patients are cared for that we can improve on so next to that right column are a lot of line items of initiatives and you identified some and we've identified some, there's a complete picture there and we just don't know it. It exists but we don't know it. And I think maybe the role is that ARC would help fill that in and as it is been filled in, change that financial impact that has improved the lives of the people that are benefiting from initiatives that ARC AHRQ has identified work with scientific evidence.

It's interesting Tom Nolan unfortunately passed away, would really appreciate your comment because he had never done a logic model and so I said we need a logic model for this $30 million stimulus grant that we want to put in our population health so we did a logic model and he used that to show where using our best prediction in theory we didn't know what the we were talking about better do some innovation. I thought it was extremely illuminating and I think that is what you are saying is what is a logic model for this our best thinking and how do we amend it or fill it in? So that's great so we are almost out of time I did want to make one comment again about being specific we talk a lot about learning collaboratives and Paul can talk to one kind of learning collaborative of thousands of hospitals in what's called collaborative we can talk about collaborative you described and be sure to think of them in three classes one is a shared learning where communities of practice sharing what they know and another one is shared learning for innovation, where people actually are willing to test innovative ideas to get some primary information and the third is an implementation collaborative rehab evidence-based up like Million Hearts where you want to get people to do what the evidence is and it's a different collaborative so be precise about that and maybe a collaborative isn't the best mechanism maybe it's campaign defense so the evidence is and I think we are just about out of time but I had a question like teed up for Edmondo with a question Arlene and go Paul Jamie and others organization your want to know you can look at this as we will have a holistic solution to the problem of patients with complex health care needs and high cost or the other pole fuel workouts up they were we know the evidence is really good and we are going to get it right and hope that it somehow translates into better care in a broader sense. Where on that spectrum if you had to advise AHRQ to ask for annual funding, where on that spectrum@date to be? Do you have wisdom or ideas or your transformation officer you get great ideas all the time. I don't know about wisdom

I don't know is that think about that there are some areas where maybe approaches less effective perspective of someone spends her time patient health system as part of a health system leadership think about those one-off interventions in a couple of them were mentioned where there is no clear pathway on how to scale that there's not truly clear how to generate or understand the generalizable ROI and those are areas where it is not flat that was that doesn't I'm not sure what to do with that [ Indiscernible] Camden love that idea and even today we had conversations still don't know how actually do that and lighter than a challenge it is how do you make a skill that in that's less useful on the other hand the pig on the other side of that extreme these big high-level concepts and frameworks that don't have real-world changes we are dealing with daily are less useful great you'll go frameworks think about how you will approach your own research portfolio for example but there's less relative to what we are doing on a day-to-day basis if you're not addressing the implications on our own strategic decisions that we deal with on a day-to-day basis given the patient's and go back to digital if you're not about digital M&A payment provider for not mentioned as well all of that makes in two day-to-day [ Indiscernible] mumble Mac hard to understand proximity that is less relevant as well some sweet spot in the middle between those we have to find where that sweet spot is that early to the paper and specific quotes out of that around the bottle and structures in healthcare appear change in a quote or function surface will remain structures changing all-time we are doing with the need on that function frequently need at the same time though there's a persistent frustration not in observance of Health Care Innovation but leaders in healthcare delivery frustration quoting limitation of solution. As quoted solutions quote without evidence review to assess their value for the implementation or proper evaluation afterwards that is critical one example Guinness digital is just right with and you guys are right on it on that. And we are dealing with that on a day-to-day basis and to me that's very proximal to what we do every day and later on in the paragraph this is under the evidence section more evidence run the effectiveness of interventions and delivery approaches as well that support the implementation and strategies for health system improvement again the idea is that we really need that evidence to help us for me is what I call evidence-based management and I have to make decisions every day and how is what AHRQ is doing allowing me and supporting and driving that decision and again going back to some concepts around my dealing with innovation and AI and let's not get into Blockchain by the way and payment models and that proximal and if you are not right, then that's were back back research model supports that is embedded research about where you bed something with research skills and mixed methods qualitative especially epigraphic embed them in the work as part of the team understanding that mail is not back I don't think that the objective. I advised him that that that what we did do something we call evaluates the role is embedded statisticians in the skills you might need and their job is to be very proximal to what are operating plans and goals and strategies are in to drive based off of that. Biased answers I think it's a great approach. Back although not discussing this today there's a K-12 learning health system training program you guys have invested in pretty heavily which I think is terrific I don't know what they're learning that pediatric programs there's an opportunity here for I think the agency to say well we are actually not interested in at overuse of CT scan and a small department of neurosurgery at the Hospital unless you can show us how Betty that Crane actually leads to solving problems data greater scale as you were saying bringing in other issues I remember talking to somebody from a prestigious acumen medical center one of the fellows on mentoring probably and never occurred to this person that there is a whole lot going on the institution about overuse other than antibiotics and there was something called a CFO and people doing data analytics able to put this in context and help sell it and never had occurred to us so frameworks as you were saying as to what we truly mean when we say we will train people to do this do a project that embeds people is critical I think. Back back I think anyone else I hate

I hate to waste 10 minutes without productive input I've been very Kathy haven't heard from you. Back back So in that team is the patient the center and we have the family and caregiver and provider team which includes the primary care of nurses clinical Associates and administrative clerk's and they coordinated the facility transitional care and they also work with doing community alignment as well for the patient. So you have that transitional care but one thing that we found incorporating best practices and trying to get them implemented and be implemented for our scale and spread is that you really need incentives and incentives to get these different practices into the field because change is a barrier. And to get those you need some incentives and so the question I have is, is it possible to look at the incentives for evaluating the different healthcare facilities and so that the metrics that evaluate I'm a five-star facility maybe we need to look at those metrics to say okay, are you implementing best practices? Is that incorporated into that metric? Are you considering what your readmission rate? Pulling in some other things and re-looking at those to try to get the facilities to be looking at changing their practices so that it is more centered on the patient.

I think again I mentioned at the beginning that considering the VA as part of the collaboration the government fundamental error because as far as I can tell the telehealth exploration of the VA is as strong as I've seen it anywhere and certainly implementation science is alive and well in the VA most of the credible scientist and implementation science are in the VA so there cosponsor for the D&I meeting along with AHRQ and Academy health and thank you for not to have called on you earlier.

Superquick from CUC I'd be remiss if I did say something about prevention when you look at the slide we've been talking about reducing the cost for multiple per page instead of multiple chronic diseases but I hope you're also thinking about tertiary prevention like eliminating those people from the left bar and if you focus on those type of activities may be many people from ending up in the left bar in the first place because there cost will go down [ Indiscernible]

You remind me we have a tendency in our field to forget people who are important thinkers and nobody remembers who they are and off somewhere wondering why nobody knows I exist and Joanne Lynn was one of the first people to point out and what you want to do is intercept people on the way to getting into stage with their multiple comorbidity centered advanced level cost I think that's really important. Okay so thank you all very much and this was I hope useful to you folks. I apologize in retrospect I really don't for raising some edgier questions but I hope they that back we need to be very critical do that

Thank you very much for such a clear presentation that keyed up excellent discussions and see you all in November

Thank you Don and thank you all.

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