**Description of Current, Intermediate, and Desired End States for
Quality Measurement**

+----------------+-----------------+----------------+-----------------+
|                | Current (2006)  | Intermediate   | End State       |
|                |                 | State (2010)   | (2014)          |
+================+=================+================+=================+
| **Brief        | Care delivery   |                | Universal       |
| Description**  | and quality     |                | diffusion of    |
|                | assessment are  |                | interoperable   |
|                | largely         |                | electronic and  |
|                | fragmented by   |                | personal health |
|                | site of care    |                | records expands |
|                | with limited    |                | the definition  |
|                | interactions    |                | of an           |
|                | across sites.   |                | "encounter" and |
|                | Electronic      |                | facilitates     |
|                | health records  |                | integration of  |
|                | support care    |                | data for        |
|                | delivery but    |                | quality         |
|                | have not been   |                | assessment and  |
|                | designed to     |                | improvement     |
|                | facilitate      |                | across sites of |
|                | assessment      |                | care. \[This is |
|                | across patient  |                | true but not    |
|                | groups or sites |                | our explicit    |
|                | of care.        |                | focus.\]        |
|                | Clinicians and  |                | Aligned quality |
|                | provider        |                | goals           |
|                | organizations   |                | explicitly      |
|                | rarely receive  |                | incorporate     |
|                | performance     |                | individual and  |
|                | reports in a    |                | collective      |
|                | timely fashion. |                | accountability, |
|                | Use of clinical |                | and include     |
|                | decision        |                | both processes  |
|                | support is not  |                | and outcomes.   |
|                | linked to       |                | Measures and    |
|                | quality         |                | CDS are         |
|                | objectives.     |                | routinely       |
|                | There is        |                | enhanced and    |
|                | limited         |                | refined by      |
|                | opportunity to  |                | examining       |
|                | refine measures |                | 'exceptions'. . |
|                | and CDS based   |                | Clinical        |
|                | on exceptions   |                | decision        |
|                | (patients who   |                | support         |
|                | do not "fit").  |                | routinely       |
|                |                 |                | improves        |
|                |                 |                | quality by      |
|                |                 |                | helping to      |
|                |                 |                | ensure that the |
|                |                 |                | right care is   |
|                |                 |                | delivered to    |
|                |                 |                | the right       |
|                |                 |                | patient at the  |
|                |                 |                | right time --   |
|                |                 |                | every time.     |
|                |                 |                | Information     |
|                |                 |                | from remote     |
|                |                 |                | sites (e.g.,    |
|                |                 |                | patients'       |
|                |                 |                | homes) and from |
|                |                 |                | electronic      |
|                |                 |                | communication   |
|                |                 |                | separate from   |
|                |                 |                | electronic      |
|                |                 |                | health records  |
|                |                 |                | is easily       |
|                |                 |                | captured --     |
|                |                 |                | securely and    |
|                |                 |                | privately.      |
+----------------+-----------------+----------------+-----------------+
| **Defining     |                 |                |                 |
| Cha            |                 |                |                 |
| racteristics** |                 |                |                 |
| **of Health    |                 |                |                 |
| Care System**  |                 |                |                 |
+----------------+-----------------+----------------+-----------------+
| > Business     | -   The payment |                | -   Pay for     |
| > Case         |     system is   |                |     performance |
| > (payment     |     largely     |                |     strategies  |
| > reform,      |     driven by   |                |     have        |
| > including    |                 |                |     evolved     |
| > incentives)  |   reimbursement |                |     from        |
|                |     for         |                |     rewarding   |
|                |     utilization |                |     high        |
|                |     of          |                |     quality     |
|                |     services,   |                |     clinical    |
|                |     regardless  |                |     care to     |
|                |     of patient  |                |     rewarding   |
|                |     outcome.    |                |                 |
|                |                 |                | patient-focused |
|                | -   Pay for     |                |     care and    |
|                |     performance |                |     efficiency. |
|                |     pilots and  |                |                 |
|                |     programs    |                | -   Financial   |
|                |     are         |                |     incentives  |
|                |     increasing  |                |     to promote  |
|                |     in number   |                |     higher      |
|                |     but do not  |                |     levels of   |
|                |     address     |                |     quality     |
|                |     episodes of |                |     across      |
|                |     care.       |                |     diverse     |
|                |                 |                |     heath care  |
|                | -   The market  |                |     settings    |
|                |     perceives   |                |     are used to |
|                |     the cost of |                |     improve the |
|                |     quality     |                |     current     |
|                |     reporting   |                |     system.     |
|                |     to be       |                |                 |
|                |     higher than |                |                 |
|                |     the benefit |                |                 |
|                |     of          |                |                 |
|                |     incentives, |                |                 |
|                |     but         |                |                 |
|                |     generally   |                |                 |
|                |     supports    |                |                 |
|                |     movement    |                |                 |
|                |     toward      |                |                 |
|                |     payment     |                |                 |
|                |     based on    |                |                 |
|                |     value.      |                |                 |
|                |     While there |                |                 |
|                |     is little   |                |                 |
|                |     information |                |                 |
|                |     on the cost |                |                 |
|                |     of          |                |                 |
|                |     reporting,  |                |                 |
|                |     many        |                |                 |
|                |                 |                |                 |
|                |    institutions |                |                 |
|                |     rely on     |                |                 |
|                |     manual      |                |                 |
|                |     chart       |                |                 |
|                |                 |                |                 |
|                |    abstraction. |                |                 |
+----------------+-----------------+----------------+-----------------+
| > Clinical     | Clinical        |                | Clinical        |
| >              | documentation   |                | documentation   |
|  documentation | can occur in    |                | is standardized |
|                | many places in  |                | and structured  |
|                | the medical     |                | for             |
|                | record -- and   |                | query/analysis. |
|                | "offline" \--   |                | Increased       |
|                | complicating    |                | linkages        |
|                | search          |                | between         |
|                | algorithms.     |                | clinical care   |
|                | Most clinical   |                | and population  |
|                | documentation   |                | health          |
|                | is free text    |                | registries are  |
|                | and             |                | the norm.       |
|                | no              |                |                 |
|                | n-standardized. |                | Focused         |
|                | Templates in    |                | documentation   |
|                | commercial EHRs |                | templates are   |
|                | are available,  |                | integrated into |
|                | but are         |                | workflow with   |
|                | optional and    |                | CDS that        |
|                | highly          |                | improve         |
|                | customized --   |                | provider        |
|                | and cannot      |                | efficiency and  |
|                | support fair    |                | patient safety  |
|                | comparisons.    |                |                 |
+----------------+-----------------+----------------+-----------------+
| > Clinical     | -   CDS         |                | Clinicians,     |
| > decision     |     consists    |                | patients and    |
| > support      |     mostly of   |                | others receive  |
|                |     alerts and  |                | relevant        |
|                |     order sets  |                | information in  |
|                |     as part of  |                | context to help |
|                |                 |                | them make       |
|                |    computerized |                | better          |
|                |     physician   |                | decisions,      |
|                |     order entry |                | prevent errors, |
|                |     systems.    |                | and improve     |
|                |                 |                | care quality    |
|                | -   CDS is not  |                | and outcomes    |
|                |     explicitly  |                |                 |
|                |                 |                | CDS is          |
|                |    synchronized |                | synchronized    |
|                |     with        |                | with            |
|                |     quality     |                | p               |
|                |                 |                | opulation-based |
|                |    measurement. |                | quality         |
|                |                 |                | reporting.      |
|                | -               |                |                 |
|                | Knowledge/tools |                | CDS does not    |
|                |     are not     |                | detract from    |
|                |                 |                | workflow, but   |
|                |   interoperable |                | rather CDS will |
|                |     (each       |                | reduce adverse  |
|                |     vendor/     |                | events, improve |
|                |     provider    |                | health          |
|                |     recreates   |                | maintenance and |
|                |     the wheel). |                | chronic disease |
|                |                 |                | management,     |
|                | -   Adoption is |                | improve         |
|                |     lim         |                |                 |
|                | ited/difficult. |                | efficiency of   |
|                |                 |                | health care     |
|                | -   Guideline   |                | service, and    |
|                |     and measure |                | reduce costs    |
|                |     developers  |                |                 |
|                |     do not work |                | Three pillars   |
|                |     with        |                | of guidance     |
|                |     electronic  |                | will lead the   |
|                |     health      |                | future CDS      |
|                |     record      |                | enhancements to |
|                |     vendors.    |                | improve health  |
|                |                 |                | and healthcare: |
|                |                 |                |                 |
|                |                 |                | -   Best        |
|                |                 |                |     knowledge   |
|                |                 |                |     available   |
|                |                 |                |     when needed |
|                |                 |                |                 |
|                |                 |                | -   High        |
|                |                 |                |     adoption    |
|                |                 |                |     and         |
|                |                 |                |     effective   |
|                |                 |                |     use         |
|                |                 |                |                 |
|                |                 |                | -   Continuous  |
|                |                 |                |     improvement |
|                |                 |                |     of          |
|                |                 |                |     knowledge   |
+----------------+-----------------+----------------+-----------------+
| > Data capture | Data capture is |                | HITSP           |
|                | n               |                | recommends      |
|                | on-standardized |                | standards for   |
|                | (very few       |                | capture of key  |
|                | required        |                | clinical data.  |
|                | fields)         |                | Fields required |
|                |                 |                | for decision    |
|                | Nomenclature is |                | support and     |
|                | no              |                | quality         |
|                | n-standardized. |                | assessment are  |
|                |                 |                | required to be  |
|                |                 |                | documented.     |
+----------------+-----------------+----------------+-----------------+
| > Data         | Clinical data   |                | Data can be     |
| > aggregation  | is aggregated   |                | aggregated      |
|                | by providers    |                | across          |
|                | and payers in   |                | providers and   |
|                | proprietary     |                | payers to       |
|                | databases that  |                | support         |
|                | are not         |                | longitudinal    |
|                | interoperable   |                | quality         |
|                | -- OR into      |                | measurement at  |
|                | stand-alone     |                | the patient,    |
|                | registries and  |                | physician,      |
|                | related         |                | physician       |
|                | databases.      |                | group, plan and |
|                | Hospital        |                | hospital level. |
|                | quality data is |                |                 |
|                | aggregated by   |                | Longitudinal    |
|                | CMS for a       |                | measurement     |
|                | limited number  |                | systems capture |
|                | of conditions   |                | the performance |
|                | and measures.   |                | of multiple     |
|                | Physician       |                | providers       |
|                | quality data is |                | caring for a    |
|                | aggregated in   |                | patient;        |
|                | pilots in a few |                | examine how     |
|                | geographic      |                | well care is    |
|                | areas.          |                | provided across |
|                |                 |                | transitions to  |
|                | These           |                | different       |
|                | individual      |                | settings (e.g., |
|                | initiatives do  |                | hospital to     |
|                | not             |                | nursing home);  |
|                | comprehensively |                | and, most       |
|                | assess provider |                | important,      |
|                | performance     |                | evaluate        |
|                | since the data  |                | patient         |
|                | collected are   |                | outcomes over   |
|                | often           |                | time. The same  |
|                | insufficient to |                | data are also   |
|                | reliably        |                | used to report  |
|                | measure quality |                | to population   |
|                | and efficiency  |                | health          |
|                | performance.    |                | reporting and   |
|                |                 |                | surveillance    |
|                |                 |                | (e.g., real     |
|                |                 |                | time            |
|                |                 |                | b               |
|                |                 |                | iosurveillance; |
|                |                 |                | cancer          |
|                |                 |                | registries;     |
|                |                 |                | vital           |
|                |                 |                | statistics).    |
+----------------+-----------------+----------------+-----------------+
| > Population   | Providers       |                | EHRs support    |
| > reporting    | utilize         |                | transfer of     |
| > and feedback | proprietary     |                | quality data to |
| >              | information     |                | quality         |
| > \[is this    | systems for     |                | reporting       |
| > needed?\]    | performance     |                | modules or      |
|                | improvement and |                | systems that    |
|                | physician       |                | can support     |
|                | feedback.       |                | automated and   |
|                |                 |                | standardized    |
|                |                 |                | quality         |
|                |                 |                | reporting       |
|                |                 |                |                 |
|                |                 |                | Monitoring,     |
|                |                 |                | evaluation, and |
|                |                 |                | research        |
|                |                 |                | functions       |
|                |                 |                | should not be   |
|                |                 |                | divorced from   |
|                |                 |                | program design  |
|                |                 |                | and             |
|                |                 |                | implementation  |
|                |                 |                | or merely       |
|                |                 |                | appended to     |
|                |                 |                | pay-            |
|                |                 |                | for-performance |
|                |                 |                | programs.       |
|                |                 |                | Rather, their   |
|                |                 |                | success will    |
|                |                 |                | depend on       |
|                |                 |                | having a strong |
|                |                 |                | learning system |
|                |                 |                | that is         |
|                |                 |                | intrinsic to    |
|                |                 |                | the design and  |
|                |                 |                | activities of   |
|                |                 |                | the program.    |
|                |                 |                | Such a learning |
|                |                 |                | system would    |
|                |                 |                | build on        |
|                |                 |                | previous        |
|                |                 |                | experiences and |
|                |                 |                | enable Medicare |
|                |                 |                | to better       |
|                |                 |                | fulfill its     |
|                |                 |                | congressional   |
|                |                 |                | mandate to      |
|                |                 |                | serve           |
|                |                 |                | beneficiaries.  |
|                |                 |                |                 |
|                |                 |                | A successful    |
|                |                 |                | pay-            |
|                |                 |                | for-performance |
|                |                 |                | program must    |
|                |                 |                | encompass the   |
|                |                 |                | elements of a   |
|                |                 |                | true learning   |
|                |                 |                | system,         |
|                |                 |                | including       |
|                |                 |                | having strong   |
|                |                 |                | leadership, a   |
|                |                 |                | shared vision,  |
|                |                 |                | and an          |
|                |                 |                | environment     |
|                |                 |                | that allows for |
|                |                 |                | action in       |
|                |                 |                | response to     |
|                |                 |                | observations    |
|                |                 |                | (including the  |
|                |                 |                | opportunity to  |
|                |                 |                | learn from      |
|                |                 |                | mistakes).      |
+----------------+-----------------+----------------+-----------------+
| > Data         | -   IFMC hosts  |                | A body governed |
| > stewardship  |     hospital    |                | by multiple     |
|                |     quality     |                | stakeholders    |
|                |     data on     |                | sets uniform    |
|                |     behalf of   |                | operating rules |
|                |     CMS.        |                | and standards   |
|                |                 |                | for sharing and |
|                | -   No          |                | aggregating     |
|                |     consensus   |                | public and      |
|                |     regarding   |                | private sector  |
|                |     utility of  |                | data on quality |
|                |     centralized |                | and efficiency; |
|                |     'vs'        |                | offers guidance |
|                |                 |                | on              |
|                |   decentralized |                | implementation  |
|                |     strategies  |                | of such         |
|                |     for         |                | national        |
|                |     aggregating |                | operating rules |
|                |     data for    |                | and standards;  |
|                |     quality     |                | and provides a  |
|                |     assessment. |                | framework for   |
|                |     Multiple    |                | collecting,     |
|                |                 |                | aggregating and |
|                |    stakeholders |                | analyzing data. |
|                |     hold        |                |                 |
|                |     relevant    |                |                 |
|                |     data with   |                |                 |
|                |     limited     |                |                 |
|                |     access to   |                |                 |
|                |     others'     |                |                 |
|                |     data.       |                |                 |
+----------------+-----------------+----------------+-----------------+
| > Public       | Quality         |                | A designated    |
| > reporting    | alliances       |                | body ensures    |
|                | prioritize      |                | the reliable    |
|                | implementation  |                | collection and  |
|                | of NQF-endorsed |                | national        |
|                | measures.       |                | reporting of    |
|                | Providers also  |                | these measures  |
|                | face demands    |                | through a data  |
|                | for information |                | repository      |
|                | from States and |                | system that     |
|                | others that use |                | includes        |
|                | n               |                | auditing        |
|                | on-standardized |                | functions and   |
|                | quality         |                | public          |
|                | measures.       |                | reporting       |
|                |                 |                | methods. These  |
|                |                 |                | two pieces need |
|                |                 |                | to ensure they  |
|                |                 |                | are capable of  |
|                |                 |                | data collection |
|                |                 |                | at the          |
|                |                 |                | individual      |
|                |                 |                | patient level   |
|                |                 |                | and open to     |
|                |                 |                | participation   |
|                |                 |                | by all payers   |
|                |                 |                | and providers.  |
|                |                 |                |                 |
|                |                 |                | Three overall   |
|                |                 |                | appr            |
|                |                 |                | oaches---public |
|                |                 |                | disclosure of   |
|                |                 |                | performance     |
|                |                 |                | data, payment   |
|                |                 |                | policies, and   |
|                |                 |                | performance     |
|                |                 |                | improvement     |
|                |                 |                | processes---can |
|                |                 |                | all provide     |
|                |                 |                | strong          |
|                |                 |                | incentives for  |
|                |                 |                | change to       |
|                |                 |                | providers (both |
|                |                 |                | clinicians and  |
|                |                 |                | institutions),  |
|                |                 |                | purchasers, and |
|                |                 |                | beneficiaries.  |
|                |                 |                | But they all    |
|                |                 |                | depend on       |
|                |                 |                | availability of |
|                |                 |                | accurate,       |
|                |                 |                | reliable, and   |
|                |                 |                | valid           |
|                |                 |                | performance     |
|                |                 |                | measures. These |
|                |                 |                | measures can    |
|                |                 |                | serve as the    |
|                |                 |                | foundation for  |
|                |                 |                | public          |
|                |                 |                | reporting       |
|                |                 |                | programs        |
|                |                 |                | intended to     |
|                |                 |                | promote         |
|                |                 |                | accountability  |
|                |                 |                | among providers |
|                |                 |                | and aid         |
|                |                 |                | consumers in    |
|                |                 |                | making informed |
|                |                 |                | choices.        |
|                |                 |                |                 |
|                |                 |                | In the future,  |
|                |                 |                | the lessons     |
|                |                 |                | learned through |
|                |                 |                | the measurement |
|                |                 |                | of performance  |
|                |                 |                | and the         |
|                |                 |                | subsequent      |
|                |                 |                | analysis of     |
|                |                 |                | performance     |
|                |                 |                | data should be  |
|                |                 |                | publicly        |
|                |                 |                | reported. This  |
|                |                 |                | information     |
|                |                 |                | should be       |
|                |                 |                |                 |
|                |                 |                | communicated    |
|                |                 |                | quickly and     |
|                |                 |                | clearly in a    |
|                |                 |                | manner that     |
|                |                 |                | makes it useful |
|                |                 |                | to a wide       |
|                |                 |                | variety of      |
|                |                 |                | decision        |
|                |                 |                | makers,         |
|                |                 |                | patients,       |
|                |                 |                | health care     |
|                |                 |                | providers,      |
|                |                 |                | payers, health  |
|                |                 |                | plans, and      |
|                |                 |                | regulators who  |
|                |                 |                | are all         |
|                |                 |                | involved with   |
|                |                 |                | this process.   |
+----------------+-----------------+----------------+-----------------+
| > Coordination | -   Quality     |                | Measure         |
| > between      |     measures    |                | developers and  |
| > quality      |     are defined |                | EHR vendors     |
| > organizat    |     without     |                | work            |
| ions/alliances |     sensitivity |                | collaboratively |
| > and health   |     to EHR      |                | to ensure that  |
| > IT vendors   |     measurement |                | data capture    |
|                |                 |                | required for    |
|                |   capabilities. |                | new measures    |
|                |                 |                | can be          |
|                | -   EHRs do not |                | automated.      |
|                |     support     |                |                 |
|                |     current     |                |                 |
|                |     quality     |                |                 |
|                |                 |                |                 |
|                |    measurement. |                |                 |
|                |                 |                |                 |
|                | -   Data        |                |                 |
|                |     collection  |                |                 |
|                |     for quality |                |                 |
|                |     measurement |                |                 |
|                |     is largely  |                |                 |
|                |     a manual    |                |                 |
|                |     effort.     |                |                 |
+----------------+-----------------+----------------+-----------------+
| >              | More than 100   |                | Policies,       |
| Intermediaries | RHIOs are in    |                | appropriate     |
| > (RHIOs,      | development     |                | oversight, and  |
| > QPICS)       | across the U.S. |                | a sustainable   |
|                | but they are    |                | business model  |
|                | not yet         |                | is in place for |
|                | interoperable.  |                | health          |
|                | Only one is     |                | information     |
|                | exchanging      |                | exchange at a   |
|                | clinical data   |                | regional, state |
|                | and merging it  |                | and national    |
|                | with claims     |                | level that both |
|                | data for the    |                | protects        |
|                | purposes of     |                | privacy and     |
|                | quality         |                | security and    |
|                | measurement and |                | enables         |
|                | reporting.      |                | appropriate     |
|                |                 |                | secondary uses  |
|                | Quality and     |                | of clinical     |
|                | Pricing         |                | data for        |
|                | Information     |                | quality         |
|                | Collaboratives  |                | management.     |
|                | (starting with  |                |                 |
|                | AQA Pilots) are |                |                 |
|                | informing the   |                |                 |
|                | ways to         |                |                 |
|                | capture,        |                |                 |
|                | aggregate,      |                |                 |
|                | analyze and     |                |                 |
|                | report quality  |                |                 |
|                | data in 6       |                |                 |
|                | different       |                |                 |
|                | regions, most   |                |                 |
|                | dependent on    |                |                 |
|                | claims data.    |                |                 |
+----------------+-----------------+----------------+-----------------+
| > EHR adoption | -   The 2005    |                | Certified       |
|                |     National    |                | products        |
|                |     Ambulatory  |                | require systems |
|                |     Medical     |                | designed to     |
|                |     Care Survey |                | collect more    |
|                |     found that  |                | meaningful,     |
|                |     24% of      |                | standardized    |
|                |     physicians  |                | electronic data |
|                |     had a full  |                | for multiple    |
|                |     or partial  |                | purposes.       |
|                |     EHR in      |                |                 |
|                |     their       |                |                 |
|                |                 |                |                 |
|                |    office-based |                |                 |
|                |     practice.   |                |                 |
|                |     Further     |                |                 |
|                |     analysis of |                |                 |
|                |     this study  |                |                 |
|                |     shows that  |                |                 |
|                |     only 9% of  |                |                 |
|                |     physicians  |                |                 |
|                |     used a more |                |                 |
|                |     s           |                |                 |
|                | trictly-defined |                |                 |
|                |     EHR.        |                |                 |
|                |                 |                |                 |
|                | -   The 2005    |                |                 |
|                |                 |                |                 |
|                | CMS/Mathematica |                |                 |
|                |     Hospital    |                |                 |
|                |     survey      |                |                 |
|                |     reported    |                |                 |
|                |     that 83% of |                |                 |
|                |     hospitals   |                |                 |
|                |     used        |                |                 |
|                |     electronic  |                |                 |
|                |     lab results |                |                 |
|                |     with        |                |                 |
|                |     decision    |                |                 |
|                |     support;    |                |                 |
|                |     about half  |                |                 |
|                |     used        |                |                 |
|                |     electronic  |                |                 |
|                |     clinical    |                |                 |
|                |     notes and   |                |                 |
|                |     lab orders; |                |                 |
|                |     and about a |                |                 |
|                |     quarter     |                |                 |
|                |     used        |                |                 |
|                |     electronic  |                |                 |
|                |     reminders   |                |                 |
|                |     for         |                |                 |
|                |                 |                |                 |
|                | guideline-based |                |                 |
|                |                 |                |                 |
|                |   interventions |                |                 |
|                |     and         |                |                 |
|                |                 |                |                 |
|                |  e-prescribing. |                |                 |
|                |                 |                |                 |
|                | -   The "Doctor |                |                 |
|                |     Office      |                |                 |
|                |     Qual        |                |                 |
|                | ity-Information |                |                 |
|                |     Technology" |                |                 |
|                |     (DOQ-IT)    |                |                 |
|                |     pilot       |                |                 |
|                |     project,    |                |                 |
|                |     mandated by |                |                 |
|                |     MMA, is     |                |                 |
|                |     aimed at    |                |                 |
|                |     paying for  |                |                 |
|                |     performance |                |                 |
|                |                 |                |                 |
|                |    specifically |                |                 |
|                |     related to  |                |                 |
|                |     physician   |                |                 |
|                |     office      |                |                 |
|                |     practices   |                |                 |
|                |     that        |                |                 |
|                |     implement   |                |                 |
|                |     changes in  |                |                 |
|                |     their use   |                |                 |
|                |     of          |                |                 |
|                |     information |                |                 |
|                |     technology. |                |                 |
+----------------+-----------------+----------------+-----------------+
| > Privacy and  | HIPAA protects  |                | A national      |
| > Security     | the privacy of  |                | framework for   |
| > policies,    | patients'       |                | the secondary   |
| > including    | health          |                | use of health   |
| > secondary    | information:    |                | data that       |
| > uses of data |                 |                | includes a      |
|                | Patient         |                | robust          |
|                | Protection:     |                | infrastructure  |
|                |                 |                | of policies,    |
|                | -   Access to   |                | standards, and  |
|                |     medical     |                | best practices  |
|                |     records     |                | facilitates the |
|                |                 |                | broad and       |
|                | -   Notice of   |                | multiple        |
|                |     privacy     |                | purpose         |
|                |     protections |                | collection,     |
|                |                 |                | storage,        |
|                | -   Limits on   |                | aggregation,    |
|                |     use of      |                | linkage, and    |
|                |     personal    |                | transmission of |
|                |     medical     |                | health data     |
|                |     information |                | with            |
|                |                 |                | appropriate     |
|                | -   Prohibition |                | protections for |
|                |     on          |                | legitimate      |
|                |     marketing   |                | secondary use.  |
|                |                 |                | Rules and       |
|                | -   Stronger    |                | guidelines will |
|                |     state laws  |                | have been put   |
|                |                 |                | in place early  |
|                | -               |                | on in the       |
|                |    Confidential |                | process in      |
|                |                 |                | order to enable |
|                |  communications |                | quality         |
|                |                 |                | programs to     |
|                | -   Complaints  |                | continue        |
|                |                 |                | uninterrupted   |
|                | Healthplans and |                | by secondary    |
|                | Providers       |                | data issues or  |
|                |                 |                | challenges.     |
|                | -   Limits on   |                |                 |
|                |     use of      |                | Appropriate     |
|                |     personal    |                | confidentiality |
|                |     medical     |                | protections are |
|                |     information |                | in place for    |
|                |                 |                | the submission  |
|                | -   Employee    |                | of patient data |
|                |     training    |                | that are in     |
|                |     and privacy |                | strict          |
|                |     officer     |                | compliance with |
|                |                 |                | the regulations |
|                | -   Public      |                | of the Health   |
|                |     r           |                | Insurance       |
|                | esponsibilities |                | Portability and |
|                |                 |                | Accountability  |
|                | -   Equivalent  |                | Act. Potential  |
|                |                 |                | problems of     |
|                |    requirements |                | patients opting |
|                |     for         |                | out to have     |
|                |     government  |                | their data      |
|                |                 |                | included in a   |
|                | Outreach and    |                | data repository |
|                | Enforcement     |                | are addressed   |
|                |                 |                | and impacts on  |
|                | -   Guidance    |                | accurately      |
|                |     and         |                | assessing the   |
|                |     technical   |                | quality of care |
|                |     assistance  |                | on both the     |
|                |     materials   |                | national and    |
|                |                 |                | community       |
|                | -   Conferences |                | levels are      |
|                |     and         |                | understood.     |
|                |     seminars    |                |                 |
|                |                 |                |                 |
|                | -   Information |                |                 |
|                |     line        |                |                 |
|                |                 |                |                 |
|                | -   Civil and   |                |                 |
|                |     criminal    |                |                 |
|                |     penalties   |                |                 |
+----------------+-----------------+----------------+-----------------+
| **Implications |                 |                |                 |
| for Key        |                 |                |                 |
| Stakeholders:  |                 |                |                 |
| roles or       |                 |                |                 |
| issues**       |                 |                |                 |
+----------------+-----------------+----------------+-----------------+
| **Consumers**  | Interest in     |                | Enhanced        |
|                | quality         |                | computer and    |
|                | information is  |                | health literacy |
|                | increasing      |                | support the use |
|                | rapidly but     |                | of customized   |
|                | available       |                | reports and     |
|                | information in  |                | consumer        |
|                | not             |                | engagement with |
|                | c               |                | care.           |
|                | onsumer-focused |                |                 |
|                | and is          |                |                 |
|                | fragmented.     |                |                 |
+----------------+-----------------+----------------+-----------------+
| **Providers**  |                 |                |                 |
+----------------+-----------------+----------------+-----------------+
| **Purch        |                 |                |                 |
| asers/Payers** |                 |                |                 |
+----------------+-----------------+----------------+-----------------+
| **             |                 |                |                 |
| Policymakers** |                 |                |                 |
+----------------+-----------------+----------------+-----------------+
| **Enablers and | Barriers        |                |                 |
| Barriers**     |                 |                |                 |
|                | -   Quality     |                |                 |
|                |     assessment  |                |                 |
|                |     has been    |                |                 |
|                |     tightly     |                |                 |
|                |     linked with |                |                 |
|                |     site of     |                |                 |
|                |     care or     |                |                 |
|                |     individual  |                |                 |
|                |     clinicians; |                |                 |
|                |     few         |                |                 |
|                |     integrated  |                |                 |
|                |     or          |                |                 |
|                |                 |                |                 |
|                |   episode-based |                |                 |
|                |     metrics     |                |                 |
|                |                 |                |                 |
|                | -   Quality     |                |                 |
|                |     measurement |                |                 |
|                |     relies on   |                |                 |
|                |     linkages    |                |                 |
|                |     between     |                |                 |
|                |     ambulatory  |                |                 |
|                |     & inpatient |                |                 |
|                |     records,    |                |                 |
|                |     which often |                |                 |
|                |     do not      |                |                 |
|                |     exist       |                |                 |
|                |                 |                |                 |
|                | ```{=html}      |                |                 |
|                | <!-- -->        |                |                 |
|                | ```             |                |                 |
|                | -   Robust      |                |                 |
|                |     measures    |                |                 |
|                |     not yet     |                |                 |
|                |     developed   |                |                 |
|                |     for all     |                |                 |
|                |     physician   |                |                 |
|                |     specialties |                |                 |
|                |                 |                |                 |
|                | -   Current     |                |                 |
|                |     electronic  |                |                 |
|                |     health      |                |                 |
|                |     records do  |                |                 |
|                |     not support |                |                 |
|                |     efficient   |                |                 |
|                |     data        |                |                 |
|                |     capture     |                |                 |
|                |                 |                |                 |
|                | ```{=html}      |                |                 |
|                | <!-- -->        |                |                 |
|                | ```             |                |                 |
|                | -   Clinical    |                |                 |
|                |                 |                |                 |
|                |   documentation |                |                 |
|                |     is often    |                |                 |
|                |                 |                |                 |
|                |    unstructured |                |                 |
|                |     and uses    |                |                 |
|                |     n           |                |                 |
|                | on-standardized |                |                 |
|                |                 |                |                 |
|                |    nomenclature |                |                 |
|                |                 |                |                 |
|                | ```{=html}      |                |                 |
|                | <!-- -->        |                |                 |
|                | ```             |                |                 |
|                | -   Clinical    |                |                 |
|                |                 |                |                 |
|                |   documentation |                |                 |
|                |     is          |                |                 |
|                |     sometimes   |                |                 |
|                |     not         |                |                 |
|                |     encouraged  |                |                 |
|                |     and is      |                |                 |
|                |     often the   |                |                 |
|                |     last module |                |                 |
|                |     implemented |                |                 |
|                |     by          |                |                 |
|                |     hospitals,  |                |                 |
|                |     as it       |                |                 |
|                |     requires    |                |                 |
|                |     significant |                |                 |
|                |     change      |                |                 |
|                |     management  |                |                 |
|                |     for         |                |                 |
|                |     clinicians  |                |                 |
|                |                 |                |                 |
|                | Enablers        |                |                 |
|                |                 |                |                 |
|                | -   Quality     |                |                 |
|                |     alliances   |                |                 |
|                |     --          |                |                 |
|                |                 |                |                 |
|                |   collaboration |                |                 |
|                |     between     |                |                 |
|                |     providers,  |                |                 |
|                |     purchasers, |                |                 |
|                |     consumers   |                |                 |
|                |     and         |                |                 |
|                |     accreditors |                |                 |
|                |     -- are      |                |                 |
|                |     producing   |                |                 |
|                |     uniform     |                |                 |
|                |     standards   |                |                 |
|                |     for sharing |                |                 |
|                |     and         |                |                 |
|                |     aggregating |                |                 |
|                |     health data |                |                 |
|                |     and for     |                |                 |
|                |     public      |                |                 |
|                |     reporting   |                |                 |
|                |     for         |                |                 |
|                |     hospitals   |                |                 |
|                |     and         |                |                 |
|                |     physicians  |                |                 |
|                |                 |                |                 |
|                | -   Measures    |                |                 |
|                |     that span   |                |                 |
|                |     care        |                |                 |
|                |     delivery    |                |                 |
|                |                 |                |                 |
|                | ```{=html}      |                |                 |
|                | <!-- -->        |                |                 |
|                | ```             |                |                 |
|                | -   Quickly     |                |                 |
|                |     accessible  |                |                 |
|                |     ambulatory  |                |                 |
|                |     records     |                |                 |
|                |     would       |                |                 |
|                |     ensure      |                |                 |
|                |     compliance  |                |                 |
|                |     with        |                |                 |
|                |     time-based  |                |                 |
|                |     standards   |                |                 |
|                |     of care and |                |                 |
|                |     help find   |                |                 |
|                |     con         |                |                 |
|                | traindications. |                |                 |
|                |                 |                |                 |
|                | -   Standard    |                |                 |
|                |     approach    |                |                 |
|                |     for EHRs to |                |                 |
|                |     routinely   |                |                 |
|                |     produce     |                |                 |
|                |     quality     |                |                 |
|                |     data based  |                |                 |
|                |     on approved |                |                 |
|                |     measures    |                |                 |
|                |                 |                |                 |
|                | -   The         |                |                 |
|                |     designation |                |                 |
|                |     of a        |                |                 |
|                |     national    |                |                 |
|                |     health data |                |                 |
|                |     stewardship |                |                 |
|                |     entity      |                |                 |
|                |                 |                |                 |
|                | -   Pilot       |                |                 |
|                |     projects    |                |                 |
|                |     that        |                |                 |
|                |     provide     |                |                 |
|                |     leadership  |                |                 |
|                |     for a       |                |                 |
|                |     national    |                |                 |
|                |     framework   |                |                 |
|                |     and act as  |                |                 |
|                |     learning    |                |                 |
|                |                 |                |                 |
|                |    laboratories |                |                 |
|                |     to link     |                |                 |
|                |     public and  |                |                 |
|                |     private     |                |                 |
|                |     data sets   |                |                 |
|                |     and assess  |                |                 |
|                |     clinical    |                |                 |
|                |     quality,    |                |                 |
|                |     cost of     |                |                 |
|                |     care and    |                |                 |
|                |     patient     |                |                 |
|                |     experience  |                |                 |
|                |                 |                |                 |
|                | -               |                |                 |
|                |   Collaboration |                |                 |
|                |     between     |                |                 |
|                |     private and |                |                 |
|                |     public (CMS |                |                 |
|                |     and AHRQ),  |                |                 |
|                |     and between |                |                 |
|                |     the medical |                |                 |
|                |     community   |                |                 |
|                |     and         |                |                 |
|                |     purch       |                |                 |
|                | asers/consumers |                |                 |
+----------------+-----------------+----------------+-----------------+
| **Date         |                 |                |                 |
| Achieved**     |                 |                |                 |
|                |                 |                |                 |
| (Earliest --   |                 |                |                 |
| Latest)        |                 |                |                 |
+----------------+-----------------+----------------+-----------------+
| *              |                 |                |                 |
| *Assumptions** |                 |                |                 |
+----------------+-----------------+----------------+-----------------+