Gordon Schiff, director of clinical quality research and improvement at Chicagos 460-bed John H. Stroger Jr. Hospital of Cook County, credits AHRQ with giving the field of patient-safety research a jump-start.
It would be hard to underestimate all the positive things that theyve left an imprint on, Schiff says. Its hard to measure, but its left an imprint.
Some researchers are now also concerned that Congress is micromanaging the agencys budget. Starting in 2004, for example, lawmakers mandated that more than half of the money available for patient-safety research be related to information technology. There is some concern that this may ultimately stifle the very creativity some say has made the agency successful.
AHRQ still finds ways to fund practice-based research, says James Mold, professor of family and preventive medicine at the University of Oklahoma Health Sciences Center. But, mainly, AHRQ doesnt have enough money, and the money they have is pretty much earmarked by Congress.
John Hickner, a University of Chicago professor of family medicine, was part of a team that received developmental grants in 2000 and 2002 totaling about $600,000 that he says were used to establish expertise in patient-safety research at a time when little expertise in this field existed. Hickner, who was then the director of the American Academy of Family Physicians National Research Network, calls the developmental grant program visionary and says his team first studied error-reporting for primary-care physicians. The second grant funded examinations of testing processes and looked at whether the right diagnostic tests were being used and if the results were getting to the patient.
The program, however, came to an end when Congress mandated that significant portions of AHRQs patient-safety programs focus on IT. As a result, Hickner says research his team was working on stopped before it could advance to the next stage of error-prevention interventions.
It left many of us out to dry, he says. We were disappointednot with AHRQ, but with Congress. It wasnt AHRQs decision.
Schiff was also the recipient of an AHRQ developmental grant that helped grow the field of diagnosis-error research. He says IT-related patient-safety research is important, but also must be put in the context of other initiatives. IT is definitely part of the solution to patient safety, but I think there is no simple technical fix to patient safety; it has to be part of a broader approach that includes changing culture, Schiff says. Merely putting computers in healthcare is not in and of itself the solution. The ability to communicate, document and access information are all important elements of patient safety.
In addition to designating a big chunk of AHRQs patient-safety budget for IT-related studies, Schiff says the Sept. 11 terrorist attacks also led Congress to redirect money away from patient safety and toward bioterrorism research.
He says the developmental grants he, Hickner and others received were the seeds that grew into a patient-safety infrastructure of research centersa generation of investigators, ideas and programs that helped make patient safety something very evidence-based and made the U.S. a leader in the field.
The developmental centers were a very useful vehicle for sharing advances and giving people critical feedback, Schiff says. My disappointment would be in that the momentum was not continued. A lot of the seeds that AHRQ money started are still blooming, but they need some watering to keep them going.
Marge Keyes, the patient-safety team leader at AHRQs Center for Quality Improvement and Patient Safety, noted that researchers were told in advance that funding would not go on continuously, and that having additional sources of money was a requirement for getting a grant in the first place.
We let them know that the AHRQ grant is not the only source they should be looking at, Keyes says. If we had all the money in the world we could go broader and deeper, but we dont and we had to make choices.
Although the developmental grants were discontinued, Keyes says she believes the program has had a lasting impact.
All in all, those centers were successful, she says. Some may have not grown in the manner we had hoped, but I think the program was successful. Some succeeded in implementing projects way beyond our expectations.
The University of Oklahomas Mold says the underfunding of AHRQ is essentially wasting the billions of dollars that are funneled into research done by the National Institutes of Health. He explains that the findings resulting from work funded by the NIHs billions (President Bush has requested $28.9 billion for the NIH in fiscal 2008) are not put into practice because the translational research AHRQ sponsors is not getting done. There are so many discoveries piled up waiting to be implemented, he says.
AHRQ Health IT Director Jon White says he has heard these arguments and is aware of the concerns.
You can understand why the research community is upset, White says. I fully understand and sympathize greatly, butin the endour job is to do with the money what Congress tells us to do with the money.
He says AHRQs patient-safety work with IT has already yielded one important discovery.
When health IT is not done correctly, its less safe or less effective than paper-based systems, White says. The counterbalance is that, when its done right, it can have a significant impact on safety and efficiency.
When deciding what proposed IT-related patient-safety projects to fund, he says, AHRQ considers the state of the field, meaning what kind of technology is available to providers, what information is available on that technology, and what are the expectations for its use.
He adds that they also look at what research other organizations and agenciessuch as the National Library of Medicine and the Office of the National Coordinator for Health Information Technologyare funding.
We need to be careful and try to leverage others work out there and be complementary and not competing, White says. Theres not enough dollars for everyone to do the same thing.
White says AHRQ also tries to keep things practical. As a result, he says the agency is more likely to fund research on topics such as electronic prescribing or electronic medical records, rather than health information exchanges.
The National Patient Safety Foundations Gluck has served on AHRQ grant committees, and says he is impressed with the way projects are chosen for funding.
This is the most rigorous process that Ive ever seen, Gluck says. I believe it works, and the cream rises to the top.
Typically, when he has been involved, there are about 40 people on the committee whoover the course of two daysmust choose about 20 projects from more than 100 applications. Each person is assigned about 10 proposals to analyze, with each proposal reviewed by three people. The first reviewer writes an in-depth report, and the second and third write shorter evaluations, Gluck says.
Each reviewer gives a proposal a numerical score based on a projects feasibility, resource requirements, sustainability and expected impact. The proposals with the top scoresusually the top one-thirdthen get reviewed by the entire committee. An AHRQ spokeswoman, however, added that there is no set formula for how many proposals get reviewed by the entire committee but, generally, the larger the applicant pool, the smaller the percentage of those that get reviewed by the whole panel.