ESP, January 26, 2012Page 13

ESP: Public Presentation of Health System or Facility Data

1-26-2012

22”31   page 7

Molly:  And speaking for us we do have Dr. Paul Shekelle.  He is the Director of the Evidence-based Synthesis Program at the West Los Angeles VA Medical Center.  And we have Annette Totten who is an assistant professor at Oregon Health and Science University.  And Isomi Miake-Lye who is a health research specialist.  So we’d like to thank all of our presenters for joining us today.  And Paul, I have turned it over to you, so you can go ahead and expect the screen share and we will be all set to go.

Dr. Shekelle:  As you heard, I’m Paul Shekelle, and Annette Totten and Isomi are both also on the line.  This is an ESP topic, an Evidence-synthesis Program topic that we were given, Public Presentation of Health System or Facility Data about Quality and Safety: A Systematic Review.

We just need to acknowledge our collaborators and co-authors including Mary Vaiana over at Rand, and Jessica Beroes who is also on the call.  And that this, as people know, all the ESP topics are nominated by some part of VA who’s interested in the information.  And this particular one was nominated by Maris Norwood from the Office of Quality and Performance. 

The next slide, Disclosure.  I’m not going to read this slide.  But the point is is that this was conducted by the ESP, that it’s funded by VA, but anything that you see here is not necessarily the official position of the VA and that no investigators have any affiliations or financial involvement, employment, consultancies, honoraria, stock ownership or options that conflict with material presented in this report.  So that’s a standard set of disclosures.  It’s probably more relevant to clinical topics than to this topic.  But nevertheless, there it is.

All right.  So just quickly, the Evidence Synthesis Program for the people who are on the call who may be new to that, it’s sponsored by the VA Office of Research and Development and by the QUERI, the Quality Enhancement Research Initiative Program.  And what we’re supposed to do is we’re supposed to provide systematic reviews and syntheses of healthcare topics for VA policy-makers, clinicians and managers who have a need for it in order to help make clinical decisions and policy decisions.  And it is building on an existing program that was supported by the Agency for Healthcare Research and Quality, the Evidence-based Practice Center Program.  And so four of the Evidence-based Practice Center Programs that also include VA’s have been designated as ESP programs.   And they include Durham, ourselves here in Los Angeles, Portland and Minneapolis.

We sort of talked about this.  But if any of you listening on the phone decide that there’s a topic for which you’re looking to get evidence synthesis for in order to help make a policy decision or clinical decision at your VA or VISN, this is how you nominate it and now you can just go online and nominate it.  Those nominations are reviewed on a periodic basis and then some of them are developed up into topics which are then back assigned out to one of the four Evidence Synthesis Programs.

Let’s get through the Steering Committee part.  The ESP programs, again, just one sentence about how they work.  We are the experts in doing systematic reviews and meta analyses, so we are kind of a toolbox.  And so we have all the hammers and nails and chisels and saws that are needed to build things.  But for each topic we need to bring in content experts who know something about the topic.  I mean, in a clinical topic about whatever, beta blockers, we’d be talking to cardiologists and perhaps primary care doctors.  In topics about cancer we’d be talking to oncologists, et cetera.  So we bring in the technical expert panelists to help us better define the questions and to help us as we interpret the evidence.  These things are read to a peer review process and then the reports are posted on the VA website.  You can find it here.  There’s some fairly large number of them posted now.  I don’t know if the number is 20 or 30, but it’s a lot.

All right, so now onwards.  Onwards to our particular one.  This report became available in October 2011 and that is the website where you can get the whole report.  Here is the background.  Public reporting of performance data has been going on in the U.S. at least since the late 1980’s, when the so-called Health Care Financing Administration Death List was first reported, which listed the mortality rates for all hospitals that had a certain number of Medicare patients.  And that was sort of its kick-off in the modern age.  And it has advanced now to the point where in the non-VA world there is public reporting of data on almost every hospital available, at least any that participate in Medicare.  And there’s something like a hundred different—or more than a hundred different public reporting programs around the country.

VA recently, as part of its commitment to transparency has instituted a public reporting program as part of this Open Government Plan.  And so they were interested in a review in order to better understand public reporting and what might make public reporting more effective.  

The reason why our particular ESP, our particular site was assigned this review is that we have been involved in two prior reviews on the same topic.  So the first one was by the first author, Martin Marshal in 2000, and the second one had first author Connie Fung in 2008.  And to briefly review the Connie Fung article, in that review there were 45 articles, 10 which focused on health plan data, 27 focused on hospital data and 11 focused on individual provider data.  Now as we go forward you will see that the VA is not planning on doing public reporting of individual provider data, so we are not going to take that thread further forward.  So for this one we are only going to be dealing with health plan data and hospital data.

Again, in the Fung article overview these were organized by unit plan, hospital and providers.  And then by whether the outcome targeted what’s called the selection pathway or what’s called the performance pathway.  

So this slide indicates the two pathways by which public reporting is posited to potentially have an effect.  One is by selection, which means that consumers, patients, veterans, would look this kind of thing up before they selected a hospital or a health plan or a provider and that they would selectively choose providers and health plans and hospitals that had better performance for whatever it is that they happened to be interested in.

The change pathways posits that the effect is on the providers themselves, and that when information about their performance is made publicly available that stimulates them in order to change that performance to try to improve.  In the non-VA world it could be because they were afraid they might lose market share if the selection pathway was actually going to work.  Or it may just be based on feelings of professionalism that people don’t want to be viewed as anything under average, and in fact would like to be viewed as above average or being the best.

So the objectives for this review are the following.  To update the systematic review on the evidence that makes performance data publically available, namely, updating the Connie Fung review.  And to summarize current research about patients’ and families’ use of performance data and how these may be designed to maximize their use by veterans and family members.

Every ESP program has a list of key questions and these are the key questions.  What’s known about the most effective way to display this information; how do patients prefer to receive it; what is the evidence that patients or their families use this kind of data; and what’s the evidence that it actually leads to improved quality and safety.

So we’re not going to talk in any great detail here about the methods, but suffice to say that we looked through—we did a literature search for things.  We were looking for ones that had cited prior reviews and prior articles on this.  We also talked to experts and we did reference mining of existing articles.  And then we also, because public reporting is an area where we think there may be a fair amount of what’s called gray literature, meaning things that aren’t going to be published in JAMA or the New England Journal of Medicine or whatever and get onto MedLine that way, we also did a Google search looking on public reporting of quality information.  And then we took the top 30 hits from that and then reviewed them as well.

So the two reviewers, Annette and Isomi, looked at each of these for relevance.  The specific exclusion criteria were if they were about nursing homes, and that is actually a fairly big exclusion because over the last few years there’s been a lot of data about the public reporting of nursing homes, quality and evaluations of that.  But that’s not something VA is anticipating doing at this time and making public reports about VA nursing homes available.  And so that was not in our scope for this.  And then we also excluded non-systematic reviews, commentaries, news reports.  There’s a tremendous amount of this kind of stuff that’s out there in the literature which are just sort of commentaries and other kinds of opinion pieces about public reporting.

And we did the usual evidence tables and then—this is not the kind of thing that lends itself to a meta analysis.  It’s not like we can come up with a single number, you know, the effect of public reporting is 43 or whatever.  This is going to be a narrative synthesis where studies are grouped according to clinically similar categories and then the evidence is summarized narratively.

We assessed existing systematic reviews using a standard scale, which is the AMSTAR criteria.  And then we also assessed new studies using a set of quality metrics that were developed for the Fung review.  This is based both on the study design, with randomized trials and experimental trials considered as being better internal validity.  And then it also has a component about how representative the study population is, the larger study population to whom public reporting might be important.  And then we gave things a global rating.  Three stars means that we gave them a lot of weight in this final conclusion.  Two stars, moderate weight; and one star, little weight.  And they should move this way either because of their study design or because of the narrowness or the breadth of their population of interest.  Then the peer review, as I said, we went through a bunch of technical experts; we got a bunch of comments and we responded to those.

Here is where I am going to step out of the picture and I am going to turn this over to Isomi who is then going to run us through some of the preliminary results and then Annette is going to take us through the more substantive results.

Ms. Miake-Lye:  First we started with the literature search that Paul had described before.  And so that yielded the 370 titles.  And from there we screened those titles and eliminated the 261 which left us with a smaller number to actually screen in fuller detail.  And we also got some additional articles from content experts and from reference mining the articles from our initial list.  Then from that full screen we then included 18 full studies to be included in our actual report.  And then to supplement that we pulled the most relevant articles from the Fung review which would be that 37.  And so then those two comprised the body of literature that we then wrote our report about.  And the Google search, we actually did screen the top 30 hits, however we didn’t get anything new from there.  So it was either a website or tool that wasn’t really literature or otherwise we had already included it.

Dr. Shekelle:  Now we turn it over to Annette for the synthesis and the results.

Dr. Totten:   Hi, this is Annette.  I’m going to tell you a little bit about the results in this review, but I’m going to interject some other information as I go along.  Part of the reason, just to give you some background, but I was involved in this review, but at the same time that the VA was looking at this topic the Evidence-based Process Center at Oregon Health and Science University funded by AHRQ was also looking at this topic in a slightly different way.  And I was the PI on that review.  And I’ll tell you more about it, but there’s a couple of things that as we go along I’m going to interject from that review as well, make sure I make the distinction.

So the first two key questions were really about the VA was interested in the most effective way to display information to patients and families and how people prefer to receive this information on quality about health care providers that they could then use in decisions.  Similar reports have been written recently about this.  So the first part of the report which addresses question five is those reports.  And the citations are in the full report.  But basically there’s a series of three reports that came out last summer on the best practices in public reporting that were commissioned by AHRQ as part of their learning network around community-based quality initiatives.  And they were written by Judith Hibbard and Dr. Shoshanna Sofaer.  And they go through and identify some of the major issues with presenting quality information to consumers, patients and families, to non-clinicians.  And then the Robert Wood Johnson Foundation through their allying forces for quality also produced a group of documents about how to—what language to use in public reporting about hospital care, how to discuss and describe this type of information.

Basically, when you look through the report at the beginning it summarizes those reports.  And some of that’s common sense, but also a little challenging when you think about it.  It makes sense that information needs to be easy to understand and people need to have a presentation in a way that’s meaningful to them.  I think maybe the part that is important for us to think about is people who work in health care.  If they’re confused, they’ll come to this with an understanding of what quality is.  And one of the things that comes out in these reports is that in order for this type of information to be useful you really need to provide context.  So whether it’s a definition of quality, whether it’s a better explanation of what goes into these measures.  But there really needs to be more context than has been provided in the past.  And that is the basic types of results.  And then it makes sense that sometimes given the available resources, a lot of times these reports are developed and put out there, focusing on (inaudible), but not much testing.  And then what happens is people read them differently than we intended them to be read.

So basically the conclusion of the documents are that they need clearer information, they need more context.  And we need to do some sort of reality testing, real-world testing, cognitive interviewing, however you want to frame it, to make sure the quality at least in that respect of what people are taking away.  The second key question or the third key question, we sort of grouped one and two together, is about whether—how well could we perform status changes the behavior of our health care consumers.  And the results for that continue to be mixed which was the same results that’s been found in the prior reviews. 

Consumers will tell of their interest in that when you look at some of the research and they also said sometimes that they are aware of it, but when it actually comes to making a decision, these types of report cards are rarely the main factors in the decision.  Some of the qualitative work that I’ve looked at for other projects, still caught how many people will say word of mouth, they’ll ask a friend, they’ll ask another physician as opposed to referring to these types of reports.

There’s some indication that this isn’t true across the board, that people who are aware of public reports will, including reasons to avoid a hospital or a health plan, or as in the other work I’m doing, a nursing home.  This is a low performer.  But it doesn’t necessarily mean that if you’re a high performer you’re going to get picked more often.  If that makes sense.

And then our third key question was really about does this lead to quality improvement.  So whether it leads to quality improvement because providers want to do a good job which we hope is part of it, or just because they’re worried they’ll lose market share or whatever with patients.  Basically there hasn’t been a lot of additional research from the prior reviews.  We found a handful of new studies and we incorporated them in the summary.  And if you look at the full report you’ll see the summary.  And also the new ones do find some effects, but the effects are really small.  So the overall conclusion of the prior review isn’t changed by the new data, that’s what it comes down to.  

And this last sentence on the slide is the California Hospital Outcomes project.  It’s kind of been a lead into some of my presentations discussions.  But there have been some things that happened with the California Hospital Outcomes project that were evaluated the late ‘90’s, 1998.  And there wasn’t much effect found.  Most of the public hospitals reported that they knew about it but it didn’t change the way they provided care or the responses that they used to identify areas that they might focus on in a quality improvement activity.  The same project also reflects health plans.  And there was a more recent study done in 2005 that was never published, but was in the form of challenges we’ll get to in just a second.  And they actually found a lot more uptake with the public in terms of—there are about 28,000 visitors to the website and they handed out 100,000 of these paper copies.  And it looked like with that bigger uptake by the public that the hospitals, and medical groups which reported that they did actually focus on some of the areas that were reported in the report that they were changing the way they delivered care.  Which would lead to the limitations.  A couple of things we wanted to mention and talk to people maybe about we can ask questions, is that we know that there are lot of reports being produced out there.  The Community Value Changes funded by AHRQ are doing (inaudible).  We know there was a study a few years ago out of the University of Minnesota that listed how many reports have been done.  

But when you look in the literature for evaluations of the public reporting policy, you don’t find a lot of stuff.  It happened with the people involved in the California reports.  We talked to them about it.  One of the things they thought was—when they did it the first time they thought it was news, and it was worth publishing in a medical journal.  When they did it the second time it was more internally (inaudible).  It is published on the website.  But they didn’t feel that it merited a journal article.

So one of the things we’re concerned about and why we wrote (inaudible) papers, they’re looking at gray literature, which is the lay papers, reports, evaluations not published in the peer review journal is that we think there may be—we know there’s a lot of public reporting activity going on.  We think there may be some evaluation activity going on that we’re not finding that could be helpful even if people don’t see it as individually helpful, but if it was simplified it might be helpful to the field at large. 

In order to explore that in my other role, the review that we did for AHRQ at Oregon Health and Science, we did send out sort of an email request to about 150 people in organizations that we knew produced public reports and asked them if they’ve evaluated the report,  if they’d share that with us.  And we only had nine responses.  And most of those were we havn’t evaluated it.  We had one or two people who, in one case, pointed us toward an article we knew about.  And in one case provided us with some preliminary data that they have given on to their state legislature but have not published anywhere.  

So that’s one of the things we’re concerned about. It is a limitation, this review basically has focused on peer review.  I wanted to show you the next slide which is related to this, maybe things that aren’t out there, is what public reporting systems are talked about.  So this is a graph that I asked Isomi was nice enough to (inaudible) so I could show you.  Most of the research studies that were somehow being (inaudible) on a very small number of public reports.  There is a lot of work around the New York State Cardiac Reporting System because it was one of the first.  And because it was very controversial at the time.  It reported mortality rates for hospitals, for CABG procedures, and then in response to a lawsuit, the New York State Health Department has agreed to release some data on a very general level.  It was never their intent to release it.  Nevertheless, it was released.  It became part of the procedure that they released for hospital and surgeon level of mortality rates for their cardiac procedures.  And Pennsylvania joined in on that.  .

So that’s where most of the research has been done, and that’s been around for awhile.  CAHPS which is the Consumer—it used to be the Consumer Assessment of Health Plans, it now has a broader name because there’s the CAHPS version for nursing homes, health care, hospitals, medical groups.  But the research on it was basically done and it was the Consumers Assessment of Health Plans.  That’s the second most common.  And then Cleveland Health Quality Choice, you see there’s five studies (inaudible), doesn’t exist any more.  The hospitals did it for several years and then due to these systems merging and purchasing, it became too easy to see exactly what the other hospital was (inaudible) they didn’t agree on and the system for report cards was terminated.  So one of the issues is that hospitals did a lot of work in this area but it doesn’t show up in the literature either in terms of what reports are studied.

So to talk about some conclusions and some additional information.  So what we know from the published literature is that the evidence is pretty consistent that consumers either don’t know that much about public reports so they don’t use them, at least not when selecting health service providers.

We keep trying or discussing the fact that perhaps if they were designed better.  There is some discussion and I’ll tell you about our research in a second.  But it doesn’t change formatting, I mean, there’s been some experiments on formatting, whether you should use stars or arrows or whatever is out there, presented in the rank order sort of like the British do with their soccer league tables.  As a matter of fact, that’s what they call the score card, the report cards in England, they call them league tables.  But there’s also a discussion about it isn’t just how we present the data, it’s what data is presented.  Is it what consumers actually want.  And then is it available over the time they need it.

So the most I can tell is the research basically tells us they don’t need the selection.  Maybe given the chance we could make them better.  There is some impact on quality.  It’s not huge.  The effect has been pretty small.  We’ve seen—the more recent studies have shown an impact on quality of care as opposed to the older studies.  So that’s  perhaps evolving and improving.  But we think there’s a lot happening out there that we don’t know about.  Related to the selection, I’m going to let Paul tell a story before I finish. 

Dr. Shekelle:  Thanks, Annette.  And so I’m now going to give you what’s sometimes called an evidence based anecdote.  And what an evidence based anecdote is it it’s a specific little story or vignette usually about a specific person or a specific situation, but it’s been picked in order to help illustrate what the evidence—what a broader look at the evidence is on a particular topic.  And so this particular topic has to do with this concept that consumers, patients, veterans, are going to use the reports in order to help them select where to receive their health care from.  And so if—as Annette indicated, most of the incidents show it doesn’t have a big effect.  And if you thought it was going to have any effect who might you posit was more likely to have (inaudible) where you might posit that it’s more likely to have a (inaudible).  Are people just getting information and in getting lots of information in order to help make a decision.  People who are sometimes terrified --

(Audio difficulties.)

Molly:  Yeah, if you can go ahead that would be great.

Dr. Totten:  In a way by putting the slide up, so basically Paul’s story is he’s been working in this field for a long time.  And so basically the end of the story is that—there’s a lot of reasons to view public reporting besides being a primary influence on a patient and family physician.  I mean, that has always been one of the goals but VA and other organizations are very interested in transparency and they find value in providing information because it increases their reputation of being transparent and honest.  Whether that directly leads to the choice of a provider or not.  And this isn’t going away.  So despite the fact that we have Veteran’s review and other reviews that show that the published literature has documents a relatively small test, the funding and investment in public reporting continues. Both in the VA, the VA puts its information up, and AHRQ and Medicare.  Medicare compare has posted information on nursing homes, hospitals, home health agencies and dialysis facilities.  And they’re adding this year information on individual physicians and hospice.  And there is continued interest on reporting on the clinic or individual physician level, in part because that’s what patients are most interested in.  So this is not going to go away.  

But we have some real issues to address.  When we’re thinking about the different uses of public reporting and what we wanted to accomplish, then figuring how to go about really accomplish those goals better.   And then no matter what the goals is, they want people to be aware of it.  So there’s more discussion about how to make this information more accessible, more available, make it better understood.  And then part of, I would argue, one of the big issues is that a lot of times the information that’s publically available is information that’s usually available for another reason.  So it’s been collected for payment or for quality monitoring on a sort of governmental level and then it’s presented to patients.  And that may not be what patients actually need when they make a decision or what they want.

So this is all related to the future research.  The quality’s back in, all the (inaudible).

But meanwhile, I want to just tell you about a couple of resources and things that are coming down the pike on the last slide and there are some references in the report as well.  AHRQ has this website called Talking Quality which has links to the reports we talked about when we answered two questions, one and two, about what’s the best way to present this information and how the people want it.  So that Talking Quality website is a very interesting place to go if you’re interested in that topic.  Also the initiatives for community based values, things that they’re taking in regard to public reporting.  And it talks about ways to evaluate your public report if you’re doing one.  So I think—and they have a clearinghouse of public reports available that haven’t been updated recently but it’s interesting if you want to know sort of what kinds of things are out there that haven’t shown up in the published evaluation research literature.

Another thing I want to point out, somewhat self-serving, is that AHRQ did fund with EPC, Evidence-based Practice Center review which is public reporting as quality improvement strategy.  It’s one of eight in a series of reviews called Closing the Quality Gap.  AHRQ funded the Closing the Quality Gap series a few years ago that focused primarily on clinical topics, that went on diabetes, asthma, hypertension management, (inaudible), case management.  This series of eight topics is a little different.  Some of the other topics include hospice, palliative care, medical home models, payment incentives as their way of promoting quality.  So they’re much more sort of policy related topics.  And we’re been given the topic of public reporting.  This other review has been drafted and we just got the peer review comments last week.  And the final report will be available on the AHRQ Website.  Sometime after the end of February we’ll be submitting a revision the end of February.  It’s a little broader than the VA review.  It includes nursing homes and home care.  It includes information on individual physicians. And it will help to summarize some of the qualitative research that’s sort of the background to those reports.  How people prefer to have the information presented.  So that will be available, like I said, the report itself will be available on the Effective Health Care web the end of February or March.  And then there will be a series overview of all these reports that will come out sometime in June.  I wanted to tell you about that.

The other thing I wanted to tell you about that is not on the slide, so let me find my notes so I can get the name right.  Is that the AHRQ issued day before yesterday, on Tuesday, an FAO for grant projects to improve the science of public reporting.  So this is another indication that this is not a topic that’s going away.  So they plan to fund three cycles of projects around how to improve public reporting.  So if this is something you or other people are interested in, you might want to look up the AHRQ website, look for R21.  There’s a smaller grant—not the small one, that’s up to $350,000 over 1-3 years.  So I meant to tell you about that.

The other thing I wanted to tell you about which is my back to the limitations is that Cochrane which is the organization that does a lot of systematic reviews did a review on this topic that also came out this year.  So it could possibly help you to review.  The review came out in November.  However, Cochrane limits their reviews to randomized clinical trials, so only four studies were included in their review.  So I just wanted to tell you about that because that’s one of our other limitations is with the types of studies that are done on this topic sometimes makes it hard to summarize.  It looks like Paul is back on.  So Paul, can you talk so we can see if we can hear you?

Dr. Shekelle:  I don’t know, can you hear us?

Dr. Totten:  (Inaudible) so he can retroactively finish his story and then we ask questions.

Dr. Shekelle:  You finished it and I’m sure it’s fine. 

Dr. Totten:  Well, I didn’t tell the whole punch line which was that --

Dr. Shekelle:  You didn’t give the whole punch line?

Dr. Totten:  No, no, I didn't give the punch line.

Dr. Shekelle:  So the punch line is is that if you thought who might be smart enough and technophile enough and computer literate enough and access to all the best resources in order to make the most informed health care decision, you might pick somebody like this guy.  Who after he was no longer President of the United States he developed heart disease and he needed to get a coronary artery bypass graft operation.  And he got it done in the State of New York which has the Cardiac Surgery Referring System that Annette talked about.  And so the place that he got it done at was the only high outlier hospital in New York State at the time that he had the operation.  So that is an evidence-based anecdote that it is unlikely even some of the most able and informed patients are likely to use public reporting information in order to select where they’re going to get certain procedures done.  

Dr. Totten:  I think I covered most of the limitations in what I wanted to say about additional resources.  We have time for questions and additions, if Paul has other comments on the conclusions or the summary.

Molly:  Thank you, everybody.  This is Molly from CIDER.  I want to thank everybody for their patience while we were working through that technical difficulty.  And for those of you that joined us after the top of the hour are wondering how to submit a question, just go to that panel on the right hand side of your screen and click the plus sign next to question and then type your question or comment into the bottom box and press send.  And we do have—we actually don’t have any pending questions at this time.  So if you guys have any more comments, feel free to use this opportunity while we wait for people to write in.

Dr. Totten:  Well, I can tell people a little bit about the two things that I didn’t get put on the slides and I apologize for that.  One is the issue about the Cochrane review that came out that had , like I said, four studies, three of which were new of and one of which was not.  And because the Cochrane tends to have very strict inclusion criteria, the studies that are included have to be randomized control trials is often the case.  And there have been a handful of randomized control trials, but the four they included.  But they were mostly for example with Medicaid recipients picking a health plan.  So for example in Kansas, they ran (inaudible) to new enrollments in Medicaid that would get different information packets that would have the health care quality reporting information in it and some that didn’t, and then they monitored what plans they chose or whether they switched plans.  So those are the Cochrane randomized studies that have been done.

Most of their studies are in the field and we’ve didn’t really characterize the slides in the presentation but just to give you, some tend to be longitudinal studies which either, for example, compare states.  So New York was frequently compared to other states that didn’t have cardiac report card systems at the time to see if the choices of hospitals differed.  Or some of them are national.  One of the issues was evaluating Medicare compare.  It’s been basically been available nation-wide.  So the evaluations tend to look at change over time.  The problem is lots of other things happen.  So one of the issues for our future research needs and with the FAO from AHRQ on improving the science of public reporting is what more could there be a study of.  And that’s what I know people who have worked in the field have been thinking about.  So if people have ideas, you might want to apply for one of those grants.  Paul, I don’t know if you have anything else you’d like to say about that.

Dr. Shekelle:  No, nothing to add. 

Molly:  We do have a question that has come in.  Does VA typically use AHRQ determined quality metrics?  If so, is there a resource to find the AHRQ quality metrics for a specific field?

Dr. Shekelle:  Yeah.  Sit tight for a bit and I should be able to call that up for you, okay.  Oh, actually I can’t because—are you sharing my site right now, Molly?

Molly:  Yeah, I do have your site but I can take back the screen if you want to veer away.

Dr. Shekelle:  Actually, let me do this.  Okay.

Molly: Yeah, you can show us how to access it, actually, if you’d like.

Dr. Shekelle:  (Inaudible) go through the VA obviously.  So first we got to get to the VA site.  You go to AHRQ.  So here’s the Agency Health Care Research and Quality home page.  And there is all the indicators right there.  So here’s prevention quality indicators, innovation indicators, patient safety indicators, reaction quality indicators.  Does that answer the question, hopefully, of whoever asked this?  Is there a way that they can tell you, Molly?

Molly: Yeah, she just wrote, I got you, thanks.

Dr. Totten:  And then if you’re interested in what’s reported on Medicare, I don’t have control of the screen but if you go to Medicare.gov and you look at the compare sites, they all have definitions of what’s publically reported for Medicare for hospitals or nursing homes, for home care.  And they define each one and explain what’s included.  Paul, I can’t answer what’s in the VA site that’s public now, can you?

Dr. Shekelle:  And to tell you the truth, I haven’t looked at it either, but this is Medicare hospital compare right there.  So this is one that people are going to see a lot of.  And if they want—they’re also accessing—they have one to access Twitter and all that other stuff.  But here it is, okay.  And so this is hospital compare.  And so if you just put in your zip code, I’m putting in where we live here in Los Angeles.  And if you have any bandwidth here.  

Dr. Totten:  And there’s a blank there that says for professionals and if you want any background information on how the quality measures are done...

Dr. Shekelle:  Oh, we’re the very first one.  Here’s UCLA, so you can click on UCLA and up comes the profile.  And so patients who reported that their nurse always communicated well, 75% compared to the national average of 76 or California average of 71.  Patients who reported that their doctor always communicated well, again, pretty good numbers across the board there.

Dr. Totten:  Well, and you can see what he’s highlighted is the reputation and experience, process measures and outcome measures.  So it’s a variety of different measures that Medicare is making available now.

Dr. Shekelle:  Surgery in patients whose antibiotics are stopped, et cetera.  At any rate, there’s a ton of this stuff available on the Web.  

Molly:  Great, thank you both very much for walking us through that.

Dr. Totten:  And there’s one more thing.  This is changing rather rapidly and I actually just saw a presentation last week and there was CMS and other Federal agencies that have data really pushing initiatives to make it more globally accessible.  So that different types of reports and report cards can be generated.  That’s only one reason why they’re making it accessible.  But a lot more data is going to be available to people in these authorized organizations which will hopefully speed up the ability to manipulate that data and present it in a way that’s useful to a broader audience.  

A work group that’s been working out sort of—NOAA, the National Oceanic—I always forget what the A stands for Administration is last.  Atmospheric Administration.  They have a policy where all the data they collect is put out there and then they have (inaudible) different monitors they use to make sure it’s not misuesd or wherever.  But almost all the weather information you get is being packaged from NOAA.  So there’s a similar kind of thing happening with all of the central health information.  Among those on the other sort of smaller streams is these app producers.  I don’t know if any of you have seen, but you can actually get this hospital quality data on your iPhone and geographically keyed in to where your phone is at the time.  So the development of apps to present this data and link it to things is also happening.  There was a quality challenge under Health 2.0 which is part of the Web 2.0 to develop an app to present the hospital data last year.  So those are others things that I know about that people might be interested in.

Molly:  Excellent, thank you both very much.  We don’t—no, no more in the queue.  So do you guys have any concluding comments?

Dr. Shekelle:   Sorry for the technical difficulty, it spoiled the punch line but the message got through.  And thanks everybody for attending.

Molly:  Yes, thank you very much.  Paul, Annette, Isomi and Jessica.  We really appreciate you guys presenting for us and for getting through our technical hiccup.  And thank you to all of our attendees for joining us.  And you can join us for our next ESP session which will be on February twenty-ninth, so you can go to HSRD.gov, click on the cyber seminar catalog to register for that session.  So thank you.  This does conclude our session for today.  Thanks everybody.

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