Director's Corner

We believe that healthcare quality and healthcare equity go hand-in-hand. Given that the Digital Healthcare Research (DHR) program’s mission is focused on how digital healthcare can improve care quality, we are also focused on how digital healthcare can and must be equitable.

The non-clinical or social determinants of health (SDoH) play a critical role in positively affecting a patient’s health outcomes. That’s why we’ve funded research that helps to determine the best methods for collecting and utilizing SDOH data in busy clinical settings. Dr. Joshua Vest is comparing the effectiveness of predictive modeling versus questionnaire-based screening in identifying patients in need of social and behavioral services and Dr. Andrea Wallace evaluated the feasibility and acceptability of implementing a social needs screening process as part of inpatient discharge planning.

AHRQ is also nearing completion of its evidence- and consensus-based Digital Healthcare Equity Framework and Guide that can be used by digital healthcare developers, clinical providers, health systems, health plans, and others to consider equity intentionality when designing healthcare solutions that involve digital technologies. The framework serves as a tool to help users and other stakeholders assess whether their healthcare solutions that involve digital technologies are equitable at every phase of the digital healthcare lifecycle, including development, planning, acquisition, implementation, and maintenance. The framework and guide apply to both patient-facing and clinician-facing healthcare solutions and address the accessibility, purpose, security and privacy, usability, and safety concerns of those digital solutions.

The COVID-19 pandemic caused a surge in virtual healthcare in the United States. Telehealth is currently the dominant virtual healthcare category.

AHRQ awarded 26 research grants to explore essential questions about the delivery of healthcare during the COVID-19 pandemic. Two of those grants were specifically focused on telehealth. Dr. Daniella Meeker is examining the impact of the COVID-19 pandemic and telehealth on utilization, outcomes, disparities, and public health surveillance. Drs. Kathryn King and Kit Simpson are evaluating four telehealth programs setup by the Medical University of South Carolina in Charleston in response to the COVID-19 pandemic.

Remote patient monitoring with patient-generated health data (PGHD) is an important complement to telehealth. In addition to telehealth research, AHRQ is interested in research exploring the efficacy and safety of digital healthcare innovations that utilize virtually gathered PGHD. For example, Dr. Robert Rudin adapted a previously developed mHealth app to track patients’ self-reported asthma symptoms between clinical visits—thereby facilitating getting patients the treatment that they need in a timely manner. See below for additional information regarding AHRQ interest in PGHD.

Patient-generated health data (PGHD) are “health-related data created, recorded, or gathered by or for patients (or family members or other caregivers) to help address a health concern.” PGHD such as patient-reported outcomes (PROs), health-relevant behaviors, anthropometrics, and physiological measures can be collected through a variety of tools including patient portals, mobile applications (apps), and devices.

The potential for PGHD to impact healthcare delivery is significant. Ambulatory care clinicians base their decisions on information received from the patient, traditionally from data collected in the clinical setting. PGHD offers insights into the day-to-day health of an individual, providing patients and clinicians the ability to employ better strategies to prevent and manage acute and chronic conditions, through monitoring for remission and relapse. In addition, clinicians and scientists can use these data to generate and apply analytical techniques to improve risk prediction and diagnoses.

AHRQ developed a PGHD guide to support ambulatory care practices in 1) identifying patient cohorts who can best benefit from PGHD capture, 2) accelerating adoption of health information technology solutions to support patient transfer of data, and 3) optimizing data review by mining large quantities of PGHD to identify patterns and red flags for clinical workflows and care planning.

Furthermore, AHRQ is interested in research that explores how to effectively capture and visualize PGHD. For example, UCSF researchers studied whether pain intensity data collected from patients after dental procedures can help dental providers track patients’ pain more effectively in real time and modify prescription use. These researchers adapted and customized the user interface of an existing mobile health platform, and sent text messages to patients at pre-defined time intervals asking patients to report pain intensity and pain experience. Also, research by Dr. Ida Sim is developing, testing, and evaluating a mobile app that will integrate PRO data into the clinical workflow. Providers can review and reflect on the PRO data during clinic visits using a provider-facing dashboard within the EHR.

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

CDS research funded under this program aims to investigate methods to broadly disseminate Patient-Centered Outcomes Research (PCOR) findings into practice through shareable, interoperable CDS. Research in this area is therefore focused on innovative projects that study how to best leverage reusable, interoperable CDS resources as a means of making CDS development and implementation more efficient and thereby making it easier to advance evidence into practice. For example, Dr. Patricia Dykes and her team developed a sharable, interoperable CDS tool for fall prevention to support primary care practices in both rural and urban areas. Additionally, Drs. Alex Spyropoulos and Thomas McGinn developed a CDS platform for detecting and treating venous thromboembolism that can be implemented by healthcare systems using different types of electronic health records (EHRs).

In 2021, in partnership with NORC, AHRQ launched the CDS Innovation Collaborative (CDSiC) to engage patients, clinicians, health system leaders, and many others to advance patient-centered CDS. The CDSiC has been busy developing measurement frameworks, prototyping dashboards, exploring trustworthiness of CDS, and conducting pilot projects through a variety of use cases and settings. The CDSiC also held its first annual meeting at AHRQ headquarters in Rockville, Maryland in May 2023.

Research is needed in two key areas: how digital healthcare systems can improve patient safety and how digital healthcare systems themselves can be safely used and implemented. AHRQ-funded research provides critical evidence in both areas.

For example, Dr. Jason Adelman is evaluating the effectiveness of displaying patient photos in EHR systems to prevent wrong-patient errors when using computerized provider order entry systems. He is also conducting research to develop and validate new medication safety measures needed for automatically identifying violations of the “Five Rights of Medication Safety”: right patient, right dose, right medication, right route, and right frequency.

Research by Dr. Raj Ratwani, is optimizing digital healthcare systems by developing evidence-based guidelines for system design and implementation. Dr. Ratwani and his team identified safety gaps in systems through a retrospective analysis of safety event reports and used these findings to inform the development of design and implementation guidelines.

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

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

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

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

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

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

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

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

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