Remarks to the Tri-Regulator Symposium

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by HRSA Administrator Mary K. Wakefield

October 17, 2012
Washington, DC

I appreciate the invitation to be here today. I want to acknowledge the collective efforts of the National Council of State Boards of Nursing, the Federation of State Medical Boards, and the National Association of Boards of Pharmacy for your farsighted decision to convene this meeting together.  

As with much in health care, I really believe that we benefit the health of individuals and communities when we learn from and work across sectors, across disciplines and across organizations – particularly when we can align our efforts around a shared agenda.  It isn’t easy work, but I think it’s extremely important work; and this meeting is an example of that.

Clearly, the deliberations that take place here will inform the work of your respective organizations but also your work across organizations as you move forward.  And, I anticipate that the next steps that result from your work here will help to guide and inform the activities of other stakeholders interested in your work including, of course, HRSA.

Between the focus of your work as oversight boards and the myriad programs that HRSA is responsible for there are many different touch points where your work matters to us.  More importantly it matters greatly to the populations that our programs serve – ranging from HRSA programs to prepare the next generation of health care providers to patients seen in frontier rural health clinics and urban community health centers.

Some parts of our agency, the NPDB for example, would be well known to you – others perhaps less so – so I’ll take just a minute to describe some of the programs in HRSA’s portfolio.  As I do, you should be able to see how directly and indirectly, your work matters to us.

By way of background, HRSA is often viewed as the safety net agency, charged with ensuring access to high-quality, culturally competent, primary care for all Americans.  HRSA has an $8.2 billion portfolio (FY 2012) of 80 different grant programs.  Most of these program resources go toward expanding primary care and extending health services to those who are poor, medically vulnerable or geographically isolated.  Resources are also directed toward the supply, distribution, skill, competency set and diversity of the health care workforce - primarily the primary care workforce.

The agency has about 3,000 partner organizations.   We collaborate with groups across sectors – state and local government agencies, non-profits and community-based organizations foundations, providers of clinical care, universities, research centers and others.

HRSA and licensing and regulatory boards like yours have much in common. Like you, HRSA is interested in ensuring that patient populations have ready access to safe, high-quality, appropriate health services.  

Already, in a sense the organizations you represent are modeling what we at HRSA are also doing: looking for opportunities to leverage our assets commensurate with where a safe, high-quality, efficient health care system is moving – and to do that with an eye toward creative approaches that allow us to harness technologies, new relationships, redesigned health system features and so on.

I say this because while you retain your traditional roles as guarantors of patient safety, you’re engaging this role in new ways – deploying new strategies through strengthened interprofessional collaboration and cross-disciplinary cooperation.  

Well, let me spend a few minutes talking about where we interface with your work – both directly and indirectly. A good place to start has to do with data and collecting it.  You use it to inform your thinking and we do as well. In fact, workforce data and planning are a key part of HRSA’s work.

We’re especially appreciative of our collective efforts with your respective organizations in connection with our Minimum Data Set project. The initiative is a critical priority for the National Center for Health Workforce Analysis and for HRSA.  

While my colleague Ed Salsberg will discuss the Minimum Data Set in detail tomorrow, I want to note that the overarching goal of the MDS is to create a store of information on the education, demographics, and practice characteristics of our health workforce so that we can more accurately measure capacity, identify gaps and project trends in health workforce needs.  

This work is essential to having the right number and right kinds of providers as the health care system evolves to address the needs of a growing and aging population.

At HRSA, we really appreciate your efforts to move the MDS forward for the professions you represent.  Without your commitment and your efforts “on the ground” to get buy-in from your state partners, the progress we’ve made to date would not have been possible.  We have a number of other workforce-related studies underway that may be of interest to you and that will be available about 6 months or so and will be focused on supply, distribution and diversity.  

From a different part of HRSA, we share your mission to ensure patient safety and quality services through other programs.  Among them is the National Practitioner Data Bank.  We are working hard to ensure that the public is well served by collecting and disseminating all the information that state licensing boards and hospitals need to make good licensing, credentialing and hiring decisions.

HRSA staff are appreciative of the attention you have given to our reporting compliance efforts over the last two years.  We have compared the disciplinary actions that your member boards take against the information in our Data Bank.  The data tell the story of your efforts.

For the professions you represent, medicine, nursing and pharmacy, we have received 2,255 new Data Bank reports as a direct result of your compliance efforts.  Those 2,000-plus new reports have been disclosed to other boards and hospitals over 3,000 times.

We know there is more we need to do, so for example HRSA is moving forward with our state reporting compliance efforts.  We will be comparing actions in quarterly cycles over the next 2 years.  I want to emphasize how much your good work helped us determine the best way forward.    

We are working to make the important task of ensuring complete, accurate and timely reporting to the Data Bank as burden-free as possible. Your many constructive suggestions to HRSA staff have greatly contributed to advances in Data Bank systems and operations.   We welcome your input going forward to make the information as useful and the process as easy as it can be.

The Data Bank also is improving the way information is made available to the public.   

Since 2010, the Data Bank web site has included compliance results, and more recently the web site is detailing these results in a more user-friendly format.  This year, we created web-based analytical tools and maps for the public to have NPDB data, including compliance data, available at their fingertips.  Of course, these data are non-identifiable.  

However, they provide an easy method to research compliance, malpractice and disciplinary data by state and profession.  These data are important for the public and for you.  They can be used in a variety of ways beyond typical informative statistics – for example, they be used as a baseline to set goals for compliance activities.  

The Data Bank staff are also very enthusiastic about conducting new research, and HRSA welcomes your ideas to work together on research projects.  One example of a recently completed project was initiated by the Federation of State Medical Boards.  The Data Bank and the Federation compared data to determine if the medical boards were receiving copies of NPDB reports, as required by law.  The results of that quick project led to a system change enabling the reports to be sent electronically.  That change increased the probability that your boards get vital information.

We’re very interested in hearing from you about other projects that we can work on together to improve our common mission to protect the public.  If you see other possible avenues of collaboration, please tell us.

Beyond ensuring that individual health care providers deliver safe care, we also have investments that target competencies designed to enhance care coordination and eliminate the provision of fragmented care.  While that relies on systems redesign – use of HIT for example – including EHRs – it also requires new knowledge and competencies that facilitate clinicians working in tandem – across disciplines, across sectors and sometimes, across geography.  With the ACA’s emphasis on and support of patient centered medical homes and Accountable Care Organizations, these skills are even more important.

In the reams of articles and analysis that have been written about the ACA, little emphasis has been placed on the law’s strong support for team-based, interdisciplinary care.  Many of the law‘s provisions to further quality, efficiency and patient safety move the health care system in this direction, and this orientation is important for a number of reasons.  

For example, the recent Institute of Medicine report “Best Care at Lower Prices” recommends several strategies that stress the contribution of interprofessional practice to improving care and reducing costs. The strategies IOM suggests include having health care organizations adopt cultures that encourage and support open communication among colleagues, better coordination, and meaningful teamwork.  

Our failure to do so before now, according to that report, helped fuel $750 billion in waste, inefficiency and duplicated services in the American health care system in 2009 alone.  The IOM study draws an analogy to make this point, when it says – quote:

“If home building were like health care, carpenters, electricians, and plumbers each would work with different blueprints, with very little coordination … As patients move among providers and settings, they often encounter communication and coordination problems that can result in treatment errors, duplicative services, and fragmented care.”

End quote.

Coordinated care is a very big focus for us – and operationalized in a number of ways including in deploying the Patient-Centered Medical Home.  We as a nation have been pursuing this model in fits and starts – since the concept was first proposed 45 years ago by the American Academy of Pediatrics.  Yet, through Affordable Care Act investments, we have a number of efforts underway to fully operationalize elements of the PCMH model.

For example, important to this is HRSA’s partnership with the Centers for Medicare and Medicaid Services where, in 2009, President Obama announced a 3-year demonstration project – the FQHC Advanced Primary Care Practice Demonstration – to support health centers in serving as integrated health homes for Medicare beneficiaries.

This was one of the first projects announced after the CMS Innovation Center was created by the Affordable Care Act.  Under this demo, 500 participating health center sites are transforming to patient-centered medical homes to provide targeted, accessible, continuous, and coordinated family-centered care for Medicare patients.  This year, again with ACA support, a total of $4.4 million in grants were made to assist health centers as they make practice changes, such as improved care coordination and management, necessary to become patient-centered medical homes. Individual grant awards of $55,000 were disbursed in September to 810 health centers around the nation.

On the educational side of the ledger, HRSA is currently investing in several programs to promote interprofessional clinical practice among nurses, front line workers, physicians, dentists, public health providers, and other clinical professionals.  Let me give you just 3 or 4 brief examples.

For instance, under our Nurse Education, Practice, Quality and Retention Program, we awarded over $10 million in grants for projects that create and expand innovations in interprofessional collaborative practice.  These practice models promote collaboration between nurses and other health professions and build skills in nurses to lead and support team-based care.

In addition, the Advanced Nursing Education Program awarded over $7 million in grants for projects that integrate technology into interprofessional education offerings for advanced practice nursing students who are joined by students in other health occupations.

And the Secretary announced just a few weeks back the awarding of a $4 million grant over five years to the University of Minnesota to establish a National Coordinating Center for Interprofessional Education and Collaborative Practice.  This Coordinating Center will lead efforts to improve patient safety and patient centeredness by influencing both the training of new health professionals and the practice environments of currently licensed providers.
As just one indication of how ground-breaking this initiative is, four private philanthropies have committed an additional $8.6 million to support the Coordinating Center’s projects – the Josiah Macy Jr. Foundation, the Robert Wood Johnson Foundation, the John A. Hartford Foundation, and the Gordon and Betty Moore Foundation.

Another example of our work to move towards interprofessional practice is our recent launch of the Interprofessional Oral Health Clinical Competencies Project to explore how to close the chasm between medical and dental care. The project brings together oral health and primary care providers (such as physicians, physician assistants, nurse practitioners and nurse mid-wives), health systems leaders, and funders with the aim of enhancing physicians’ ability to do oral health assessments in collaboration with dentists and other oral health providers.

The importance of this project is underscored by the fact that 4,458 regions across the nation are currently designated as dental health professional shortage areas.  

By way of background, to identify areas facing a critical shortage of primary medical, dental, or mental health care professionals, the Department of Health and Human Services relies on its HPSA designation system.  Originally created in 1978 to identify areas in need of physicians and other health care providers from the National Health Service Corps program, HPSA designation is now used by a variety of federal programs – including programs that provide grants for health professions.

On a closely related front, HRSA has partnered with three primary care certifying boards – the American Board of Family Medicine, the American Board of Internal Medicine, and the American Board of Pediatrics – to develop a program to invest in primary care faculty with the skills necessary to train residents in team-based models and systems of care.
These and other initiatives reflect how, at HRSA, we’re focusing well beyond supply and demand and really leveraging our programs to contribute to the production of clinicians with the requisite skill set to harness HIT, to work effectively in teams and make interprofessional, to engage collaborative practice that quickly becomes as commonplace as individual practicing clinicians.

We think these are key competencies – called for since the IOM reports To Err is Human and Crossing the Quality Chasm identified team-based care as prerequisite to safe care and subsequent reports noted the relationship as well.  I’d be interested in hearing what more you think we could or should be doing on this front.

In addition to investing in the competencies of clinicians, we are also focusing on the infrastructure important to supporting collaborative, team-based practice through some of our other programs.  

So, we’re seeing the ability of health professionals to work together to extend the reach of their expertise and improve access to primary and other services because of health information technology.

No longer do the patient and the provider need to be in the same location to receive quality health services.  Telehealth technologies are being used increasingly to address the shortages and the mal-distribution of health care professionals that often results in lack of access to quality health care services, whether due to geographic, economic, or other factors.
Telehealth services are increasingly becoming part of the health care mainstream.  It clearly has value in both metro and non metro areas – and it provides readily available expertise that without it, creates significant burdens for patients and their families.  Let me give you an example to illustrate the point – and why we’re working to catalyze the utilization of this technology as much as we can.

In my home state of North Dakota, telecommunications technology enables pharmacists to provide pharmaceutical care to patients from remote locations.  Telepharmacy expands access to quality health care in those communities.  

Through the North Dakota Telepharmacy Project, a licensed pharmacist at a central pharmacy site supervises a registered pharmacy technician at a remote telepharmacy site by using video-conferencing technology.  The technician prepares the prescription drug for dispensing by the pharmacist.  The pharmacist communicates face-to-face in real time with the technician and the patient through audio and video computer links.

North Dakota was the first state to pass administrative rules allowing retail pharmacies to operate in certain remote areas without requiring a pharmacist to be physically present on-site.  

This isn’t a marginal accomplishment in terms of ensuring access to quality services. Approximately 40,000 rural North Dakotans have had their pharmacy services restored, retained, or established through the project since its inception.  The project has ensured valuable access to health care in remote, medically underserved areas of the state and has added approximately $12 million in economic development to the local rural economy including adding 40-50 new jobs.

And using the power of HIT, North Dakota has medication error rates lower than the national average.  HIT can ensure access, keep costs down and be delivered safely.  There are a lot of opportunities that we’re looking at for next generation applications and clearly this area intersects with your work as well.

Some think telehealth will prove even more valuable in our evolving health care system as we focus more on value and less on volume.  In an effort to better understand the role of telehealth moving forward, HRSA partnered with the Institute of Medicine to hold a meeting this past August.  A range of experts reviewed the current evidence base for telehealth including available data and the gaps in data, and considered how technological developments including m-health, electronic intensive care units, remote-monitoring, social networking, and wearable devices, in conjunction with electronic health records, are changing the delivery of health care;  and discussed potential to further the use of telehealth to improve outcomes while controlling costs in the current health care environment.

The IOM planning group will soon issue a summary report on that meeting. You can review some of the deliberations on line at the IOM website.

Related to all this is the issue of licensure portability, seen as one of the strategies needed to improve access to care through the deployment of telehealth and other electronic practice services.  But licensure portability goes beyond improving the efficiency and effectiveness of electronic practice services.

Looking carefully at licensure requirements and barriers to cross-state practice is seen as part of a general strategy to expedite the mobility of health professionals in order to address workforce needs and improve access to care.  This approach is increasingly timely.

The Nurse Licensure Compacts model developed by the National Council of State Boards of Nursing, for example, offers what we think is an excellent model by enabling multistate licensure for both registered nurses and licensed practical/vocational nurses.

I am also pleased to report that the federal Office of Rural Health Care Policy, which is part of HRSA, has awarded Licensure Portability Grant Program grants to the Federation of State Medical Boards and the Association of State and Provincial Psychology Boards.  Each grant is for up to three years, and each grantee will receive approximately $350,000 each year.

The purpose of the Federation’s award is to reduce redundancies of obtaining physician licensure in multiple jurisdictions.  This process involves increasing utilization of the Uniform Application for Physician Licensure and developing a similar application for the physician assistant licensure.   Grant funds also will be used to develop and test licensure models to facilitate multi-state practice.

Similarly, the grant to the Association will be used to improve licensure portability and increase consistency in licensure requirements across all states for psychologists.

It is gratifying to know that state health professions licensing boards, as well as national groups representing these boards, are seeking ways to simplify the licensing process for physicians and psychologists interested in obtaining licenses across more than one state.

Through these and a number of other initiatives that we have underway, hopefully you are hearing HRSA’s focus on quality and safe care. This orientation follows the Obama Administration’s broad emphasis on these same issues.  It’s an emphasis that runs throughout the Affordable Care Act.  Our focus is tethered to broader activities supported by HHS.  A couple of examples to illustrate the point:

For example, the ACA authorized a National Quality Strategy that focuses on eliminating patient harm, reducing waste and applying innovation in how care is delivered.  Three broad strategic aims are designed to guide and assess local, state and national efforts to improve the quality of health care:

• Better Care: Improve the overall quality, by making health care more patient-centered, reliable, accessible, and safe.
• Healthy People/Healthy Communities: Improve the health of the U.S. population by supporting proven interventions to address behavioral, social and, environmental determinants of health in addition to delivering higher-quality care.
• Affordable Care: Reduce the cost of quality health care for individuals, families, employers, and government.

The strategy is designed as a living document that will be updated to reflect our progress on improving the nation’s health care. The most recent update (April 2012) listed several examples of measures that could be used to monitor progress in achieving these aims and priorities.  

The ACA also created the Partnership for Patients, a public-private collaboration to improve the quality, safety, and affordability of health care for all Americans.  The Partnership offers support to nurses, physicians, and pharmacists working in hospitals and clinics with two overarching goals:  to keep patients from getting injured or sicker, and to help patients heal without complication.  Although the Partnership is focused on elimination of all types of harm involved with hospital-acquired conditions, Adverse drug events alone account for 34.2% of all health care harm.  

This is an obvious focal point for each of your groups and an opportunity to have a dramatic impact on patient safety.  Just as a side-note: HRSA’s liaison to the Partnership’s HHS core leadership team is a pharmacist.

Another example of the patient-safety emphasis within HRSA involves our Division of Transplantation, which was awarded one of four Innovation Fellows to participate in the Department’s Innovations Fellows Program.  The HRSA Innovation Fellows Project, slated to begin later this month, will devise a mechanism for electronic identification, tracking and transport of the nation’s solid organ transplant system, using bar-coding and possible RFID technologies compatible with global standards.  These actions will minimize the potential for misdirection or other delays in organ transportation and reduce the chance of incorrect transplantation.

Everything I’ve discussed today illustrates that even as we push forward from our various perspectives on reengineering health care systems, we also need to look carefully – with an eye toward engaging new innovative approaches – even as we constantly reassess what we’re doing, what we’re requiring, and what we can do to extend the reach of safe, high-quality health care services.

I think you’ll agree with me: while many challenges await us and there is a great deal to do – this is – from our vantage point – an incredibly exciting time to be in health care.  HRSA isn’t the agency it was even 5 years ago.  Innovation, creativity and some risk-taking punctuate our work now – as we recast our programs – within the statutory frameworks that govern them. Maintaining the programs as we have historically would be a disservice to taxpayers and a drag on the forward momentum that the ACA and other tools afford us.  We’re pleased to be engaging that agenda and that orientation with you.

Thank you.