SUMMARY

Health services research provides the foundation for progress, effectiveness, and value in health care. Given the widening gap between what should be possible and what is achieved in health and health care, strengthening the pillars of the nation’s capacity to assess and improve health system performance is essential.

This was an oft-repeated observation at the National Academy of Medicine (NAM) workshop in February 2018 in Washington, DC, on Building the Evidence Base for Improving Health Care: Contributions, Opportunities, and Priorities. The workshop was sponsored by AcademyHealth, the American Association of Colleges of Nursing, the American Board of Family Medicine, the American Society of Anesthesiologists, the Association of American Medical Colleges, the Federation of American Hospitals, and the Robert Wood Johnson Foundation. Over the course of the day-and-a-half-long meeting, the participants examined funding trends, the federal and nonfederal organizations supporting health services research, the major contributions of the field, key future directions and priorities from the perspective of multiple stakeholders, and strategies for improving the ability of the field to address those priorities over the next decade.

Building on a historic base of certain path-breaking insight on how care delivery alters results, assessment of health services emerged as a field in the 1960s when federally-funded support for health care and construction of health care facilities grew rapidly, and has played a pivotal role in contributing to health policy and the delivery of health care services in the US. However, in the current policy environment, questions have been raised about the scope, scale, structure, and function of government support for health services research and, as a result, now is a critical time for the field to reflect on its past accomplishments; identify shortfalls, challenges, and future priorities; and investigate ways of organizing to effectively and efficiently address those challenges and priorities.

Current funding for health services research represents a very small percent of total research and development spending and of spending on health care in the US (0.3 percent) (Moses et al. 2015). Further, the number of projects supported by the top funders of health services research dropped overall from 2005 to 2011. Federal funding for health services research is provided by several different agencies,

each with its own goals, and amounted to about $2.5 billion in Fiscal Year 2017 (U.S. Department of Health and Human Services, 2017). These agencies include the Agency for Healthcare Research and Quality, Centers for Disease Control and Prevention, Centers for Medicare and Medicaid Services, Health Resources and Services Administration, National Institutes of Health, and Veterans Health Administration. Additionally, although not a federal agency, the Patient-Centered Outcomes Research Institute also supports health services research. While these agencies do interact in a number of ways with each other and with other agencies not represented at the meeting, including the US Departments of Housing and Urban Development, Transportation, and Labor and Commerce, there continue to be opportunities to further coordinate efforts. Outside of the federal government, a number of private foundations support health services research, including the Robert Wood Johnson Foundation, the Peterson Center on Healthcare, the Commonwealth Fund, the California Health Care Foundation, and the Blue Shield of California Foundation, among others. In addition to coordinating efforts among federal agencies, it is important to consider how to best coordinate efforts between federal agencies and private foundations.

Federal and nonfederal funding for health services research has supported a number of efforts that have had a significant impact on health care policy and the way health systems operate in areas such as cost sharing, quality improvement, payment models, and patient safety. However, health services research has been less influential in informing more nuanced management and implementation decisions that health systems face. While there is value in conducting large multiyear research projects, timeliness matters. Participants underscored the need for efforts to focus on translation, communication, and implementation of results, as well as rapid cycle research projects that aim to inform policy makers and health systems leaders about issues they face as soon as is practical. Ultimately, this means developing capacity for health services research skills, techniques, and methods among operationally-focused teams within large health systems. Incentive structures should support this engagement with funding approaches that fit that purpose, and expand the research agenda to be more inclusive of short-term, policy-driven questions and practice-based studies.

In addition, there are a number of new tools and approaches that the field of health services research can leverage to contribute advances to care quality and efficiency, including developments in predictive analytics and artificial intelligence, large data resources such as National Patient-Centered Clinical Research Network (PCORNet), data standards, model data sharing agreements, and analysis tools. In addition, other developments include shared decision-making instruments and economic and incentive modeling approaches. Consideration of factors such as

how health systems are organized, led, and reformed can improve the care that is delivered, ultimately leading to better outcomes for health care consumers. Health services researchers also continue to focus on bridging health and social services to improve access to care by addressing issues affecting access to care, including community factors, the availability of social services, and the social determinants of health. The importance of social determinants of health has been recognized for a number of years, and these factors can create a complex network of interlinked issues for health systems and researchers that require expanding the focus beyond academic health centers and hospitals to integrated primary care, community services, and public health. Within the health care system, access to care can be affected by insurance benefit designs that continually increase cost sharing. A key challenge for health services research is to determine which benefit design innovations decrease costs without having an adverse impact on health outcomes.

In order to leverage the new tools and approaches and incorporate additional data from community and other settings, it is critical to improve the national data infrastructure. Currently, cultural and political barriers, regulations, a lack of follow-through on public commitments to share data, legal challenges, and the growth of proprietary data, prohibit the sharing of data to improve health and health care. Moreover, the quality of most electronic health record and claims data is insufficient for supporting health services research and researchers often experience difficulty linking these data sources with each other, with data on relevant social factors, and with other patient-reported data. In addition to clinical and claims data, nationally representative surveys produce valuable high-quality data but many federally and state-supported surveys continue to be cut in response to budget pressures (Siddons, 2018). Policy levers for improving the data infrastructure and data sharing include developing data standards, uniform data systems across primary care settings, implementing policies to prevent data blocking and encourage truly interoperable systems, and developing additional guidance on the Health Insurance Portability and Accountability Act (HIPAA). However, a critical step to promote policy changes that might improve the data infrastructure and data access is illustrating how such changes might add value for end users in leveraging data to support research insights and health improvement.

While raising macro-level issues such as strategic coordination of research agendas and improving the national infrastructure for a fully interoperable health information system, participants emphasized various emerging strategic field focus priorities for the next decade, including:

• structured approaches to assessing, applying, and adapting the delivery system to insights and tools related to precision medicine;

• system strategies for ensuring patient safety in the face of an increasingly complex diagnostic and treatment environment;
• embedding health services research skills and tools into care delivery as a basic component of a continuously learning health system;
• establishing reliable data from the routine care experience as a secure utility enhancing evidence development, predictive modeling, and continuous care improvement;
• incorporating necessary demographic, environmental, social, and community data as an integral component of that data utility;
• devising and demonstrating the impact of innovative payment and care delivery models for improving system performance and population health;
• identification and application of quality assessment metrics that are most reliable at gauging system-wide performance in delivering care and improving health;
• positioning patient and family involvement, interests, priorities, and data as a central resource for care design and assessment;
• developing the full and effective use of artificial intelligence and machine learning as transformational resources for knowledge development and services improvement; and
• effective approaches to translating and scaling research insights, including effective expression of the consequences of inaction.

The range of the issues is so substantial that relying on spontaneous and sometimes serendipitous response capacity in the field will not meet the need. Rather, a deliberate and coordinated set of activities is required to prepare—to transform—the field. In effect, participants individually and collectively presented a call to action for the field to mobilize sustained initiatives to:

• expand the vision to account for the full range of health system forces in play;
• develop a robust taxonomy of the issue and leverage priorities for action;
• identify the tools and strategies—available and emerging—to refine and deploy in the change process;
• steward the societal-wide advancement of a culture of continuous learn ing and sharing throughout the system;
• foster the development of the data infrastructure and research teams required for real-time insights and feedback in the virtuous cycle of continuous learning;

• create a working network of stakeholders, including patients as partners in research, for expedited coordination, collaboration, and, as required, governance;
• establish shared network-wide goals and a process for tracking and adapting strategies;
• characterize the anticipated and actual results for improvement, in qualitative and quantitative personal, societal, and economic terms;
• link those real and potential returns to investments and investment requirements among stakeholders—federal and nonfederal; and
• capture and communicate the contributions, real and potential, in a broad, visible, and deliberate campaign.

In the final analysis, addressing the insights, opportunities, and obligations identified during this NAM meeting will require sustained and deliberate conversations involving stakeholders from throughout the nation. Those conversations have started, but achieving their potential for impact will require commitment and active involvement in the years ahead from the organizations represented at the meeting, not only on their own behalf, but also as recruiters, motivators, and engagers of public and private stakeholders across the nation. Congress has recently made resources available and delivered a mandate to study future federal funding in the field. This NAM meeting and publication can serve as a reference and foundation for that work, as the physical and financial health of the nation is at stake.

This page intentionally left blank.