qi-090315audio
Session date: 09/03/2015
Series: QUERI Implementation science
Session title: QUERI in the Era of the Learning Healthcare System
Presenter: Amy Kilbourne
This is an unedited transcript of this session. As such, it may contain omissions or errors due to sound quality or misinterpretation. For clarification or verification of any points in the transcript, please refer to the audio version posted at www.hsrd.research.va.gov/cyberseminars/catalog-archive.cfm.
Molly: I am very pleased to introduce our presenter today. We have Dr. Amy Kilbourne who will be speaking and she is the Director of the QUERI Program as well as a Professor of Psychiatry at the University of Michigan. We want to thank her for joining us today. Dr. Kilbourne are you ready to share your screen?
Dr. Kilbourne: Yes I am thank you.
Molly: Excellent.
Dr. Kilbourne: Great.
Molly: And we are good.
Dr. Kilbourne: Alright, thank you very much and I really appreciate the opportunity to speak to all of you today about QUERI and the changes that have gone through our program and how it might really be a leader in the era of the Learning Healthcare System. I will start first, we have a poll question for all of you. We wanted to figure out what your primary role was in the VA. At this time I think we are going to do that quick poll and get that up.
Molly: Thank you. For our attendees you will the poll question up on the screen at this time. What is your primary role in VA? We do understand that a lot of you wear many different hats in your VA position so please select your primary role. At the end of the session there will be a feedback survey that has a more extensive list from which you can choose in case you are one of the people clicking other. But your choices at this time are – student, trainee or fellow; clinician; researcher; manager or policy maker; or other. It looks like we have had almost eighty percent of our audience vote so I am going to go ahead and close the poll and share those results. Amy you can talk through those if you would like real quick, they might be hidden behind your full screen mode.
Dr. Kilbourne: No problem, great thank you. It sounds like a slight majority of all of you are researchers which is great. I am glad to see that we have students and some clinicians and managers and policy makers as well. Certainly we hope that this presentation will be useful for all of you so I will go ahead. We have another question that is a little bit more specific and that is in the second slide - What best describes your experience with implementation research? That is a core component of the QUERI Program. Do you want to go ahead and do that one real quick.
Molly: Great. So the answer options here are - have not done implementation research; have collaborated on implementation research; have conducted implementation research myself; and the last answer option I had to abbreviate a little but it is - have been a clinical or administrative collaborator on an implementation research project. So please take just a moment to fill that out, it will give Dr. Kilbourne a good indication of the level of experience we are working with today. It looks like we are at just about the same response rate almost eighty percent. So I am going to go ahead and close that and I will share those results now.
Dr. Kilbourne: Great. Good, so we have a really diverse group here, so really it kind of focuses mainly on folks that have done some collaborations on implementation research and have conducted research themselves. I am also really glad to see folks who have not done implementation research in the past or have maybe been a clinical or administrator leader/collaborator on an implementation research project. I hope to really get a lot more discussion in terms of what we can do in terms of, what QUERI is doing in terms of implementation science as we move forward into the Learning Healthcare System. I will go ahead and continue with the presentation and I just want to do a check are the slides being shown at this time?
Molly: Yes, you are good to go thank you.
Dr. Kilbourne: Great, thank you. I am going to talk a little bit about how VA Healthcare is changing and how the world is changing and how it is going to pose some challenges and opportunities for individuals who conduct implementation research in QUERI and also QUERI as a whole. I will talk about QUERI’s new thinking and direction and its updated strategic plan and our new programs and partnered evaluations and how they are being responsive to the changing VA priorities.
There have really been three major trends in the past year that have substantially altered the landscape of VA Healthcare. I think the most prominent one has been the Veterans Choice Act which has been the law that was passed last year to allow Veterans to seek care outside the VA. This is a major transformation in VA because it is essentially making the VA healthcare system more of an accountable care organization as both a payer and provider of healthcare as opposed to almost being an exclusively provider role for Veterans enrolled in the system. This is going to be a huge change in terms of how the paradigm is shifting for VA in general. In addition, we had a new Secretary Bob McDonald start a year ago and has launched a new transformation of VA called My VA. And the central theme of that is really this idea of shared services that there is no wrong door, that we do not have silos between healthcare or health insurance or things like that. The idea is that Veterans ought to be able to go to any healthcare facility and experience a list of services. This is something that was adopted in our Veterans Health Administration budget as really an ultimate priority goal of the Veterans Health Administration and where the QUERI Program sits. This means that we have been challenged by a lot of questions about what QUERI has done this past year. We have been really I think fortunate to have the support of the Office of Research and Development and the VHA National Program Offices. But they are grappling with the budget deficit and fixed budgets. And there was instituted in the past six months this idea of having a new justification process where everything had to be justified based on its linkage to new and updated VA priority goals. The question that has come up for us to justify QUERI is that - why should VHA continue to fund QUERI through medical care dollars. That is an important question because we do fund field based investigators to conduct important work that leads to improved quality of care for Veterans. We administratively sit in the Office of Research and Development that really allows us to take advantage of the national network of experts in the country who are VA investigators. At the same time, we are paid for by medical services dollars and with the challenges the VA is facing, particularly around everything from paying for Hepatitis C medication to paying for care outside the VA now that there is the Veterans Choice Act. We have been particularly challenged to further justify the added value of quality enhancement work that QUERI does in light of the fact that those same dollars are also used for medical care services.
This is I think in part of a larger trend that is going on in U.S. healthcare and important for implementation scientists to consider as well. There has been healthcare reform with the Obamacare/Affordable Care Act with Medicaid expansion in particular. The formation of healthcare exchanges at the State level that also involve these accountable care organizations which are essentially an alignment of healthcare payers and providers to provide essentially what the ultimate goal would be would be to provide the population healthcare. There is also consumer driven care trending as well with the growth of e-health and mobile health technologies and virtual care. There has also been the trend towards the use of big data by major health plans to understand and better intervene on patient populations depending on their level of clinical severity or their health service’s needs. All of this is happening also in an era of fixed budgets. So with the growth of Medicaid expansion there has been a growth of this idea of Accountable Care Organizations and also more of the concept of having capitated payments. So we are moving from an era where publicly funded healthcare used to be primarily fee for service is now moving towards bundled payments that get sent to Accountable Care Organizations on a per member per month to pay for all sorts of services. So for mental health a primary care idea would be to pay for those in combination. This is the ultimate goal is toward population health, but these are also major challenges facing the country and they are all being dealt with in different ways depending on what state you live in. And that is complicated with the population of Veterans cost over space as well.
In addition implementation research is evolving and really I think evolving in many ways to really meet the needs of better understanding these really big picture trends that are happening in VA and elsewhere. There is increased competition for independent funding, there is I think a lot of competition in NIH for health services research funding. The VA in particular has been a strong supporter of health services research for many years and continues to be. There is also growth of other major health plans such as Kaiser and others that are also getting into the business of health services research as well. At the same time though, the academic success paradigm of publishing new things and new innovations and getting more grants to build upon those, there has been a challenge in terms of whether or not that paradigm really leads to successful public health impact. This idea really was not capsulated last week at the state of the art conference. A comment that was made by Secretary Bob McDonald where he said that you know “research is great, we need research, we need innovation but we also need people to also be able to reapply or have reapplication”. He was essentially talking about the idea that it is great to have more innovation but we also need to get the work done to make an impact through what he terms ‘reapplication of those research findings into practice”. There has also been I think increased opportunities that also challenges in building the right infrastructure for regional and national data capture so that we know we are making a public health impact; that we know that these evidence based programs or treatments are actually being used and there is a level provider uptake. In many cases if we are going to be doing these large implementation studies, we need the big data to support those information loads. Oftentimes that can be challenging especially in areas where there is a need to collect more information on _____ [00:10:57] [audio skipped]. There is the issue of generalizability and the fact that many of our studies often occur in the same setting, but we really have to reach out to lower resourced settings or treatment areas that may not have the same resources that the major academic medical center. And the challenges there of building programs that were developed and tested for effectiveness in well-resourced settings whether or not it can work in lower resourced settings particularly in rural areas. It remains a challenge but also an opportunity to involve implementation scientists to think about this. Then finally I think the nature of doing implementation science is that it is really about the partnership and finding those opportunities where you have a shared agenda and shared goals with the healthcare systems, with your operations partners because in essence I think as many implementation scientists know some of the best ideas really come from our clinicians, managers and operations partners.
Learning Healthcare System has been defined and in paraphrase and this is from the Institute of Medicine as “A continuing cycle where data are generated from delivering healthcare are used to create evidence to improve care, and then again those changes are in turn subjected to careful evaluation to continue the cycle of improvement.” In essence for many of you, if you have ever been involved in implementation for example of the chronic care model or collaborative care model, there is really this notion of using data to improve practice as you go at the patient level, thinking about the Learning Healthcare System as a huge care model where you are trying to do this at a more system level and getting the pieces working in combination. There are challenges to this thinking, really this idea of being much more mindful of healthcare system, being much more mindful of what it is doing and how it is improving care. I think that the challenges remain for implementation scientists is that so many changes are happening it is really challenging to maintain that scientific rigor and that protocol that you wrote to basically maintain that in light of clinical priorities. So you may settle on a topic and a key design only to have those clinical priorities by your healthcare partners change them and that happens a lot.
The limited availability of specific improvement strategies meaning that we have these evidence based treatments but the number one question we have gotten including from our Undersecretary two weeks ago is basically – what do we have in hand to get those treatments into the hands of frontline providers across the VA nationally. What do we do? How do we transport that information? How do we get them to use? How do we get frontline providers to use evidence based treatment for practices but in a way that is also sensitive to the challenges the frontline providers face? There is also again a limited population health data to really benchmark the impact so if you want to do a large multi-site study, multi-regional study you often need to settle on _____ [00:13:45] [audio skipped] in collecting that data on a primary basis or you have to rely on good secondary data sources which may not be complete depending on what you are looking at.