**Broad Charge from the American Health Information Community**

**to the Quality Work Group**

Make recommendations to the American Health Information Community so
that health IT can provide the data needed for the development of
quality measures that are useful to patients and others in the health
care industry, automate the measurement and reporting of a comprehensive
current and future set of quality measures, and accelerate the use of
clinical decision support that can improve performance on those quality
measures. Also, make recommendations for how performance measures should
align with the capabilities and limitations of health IT.

**High-Level Vision**

The quality enterprise is integral to all aspects of health care in the
U.S. Every citizen expects consistently high-quality, safe, and
efficient care and understands the nation's unified quality agenda to
work toward that goal. All stakeholders---consumers, purchasers,
providers, regulators, policymakers, and researchers---include quality
performance, measurement, and improvement in their strategies, projects,
and routine work. Information technology and information sharing---in
the form of electronic health records, personal health records, and
other networked technologies, combines with well-constructed relevant
clinical decision support, assists consumers and providers in delivering
care and improving health in line with evidence-based practices and in
understanding how well the nation as a whole and individual providers
are doing in improving care and health status in accordance with the
priorities set in the national agenda. The national agenda is in
alignment with state and regional health care reform and policies.
Performance information is more timely, more comprehensive, and trusted
as a true measure of how well the nation is addressing high-priority
gaps in quality and safety. Performance improvement and health quality
improvement are accelerated because information systems make it easy to
make optimal care decisions. Progress on the nation's quality goals is
reinforced by public reporting on metrics and by financial incentives
for providers from employers, public and private payers that align
expectations and resources.

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

+-------------+------------------+-----------------+-----------------+
|             | Current (2006)   | Mid-State       | End State       |
|             |                  | (2010)          | (2014)          |
+=============+==================+=================+=================+
| **General   |                  |                 |                 |
| Description |                  |                 |                 |
| of Each     |                  |                 |                 |
| State**     |                  |                 |                 |
+-------------+------------------+-----------------+-----------------+
| **Brief     | Care delivery    | Quality metric  | Universal       |
| De          | and quality      | development     | diffusion of    |
| scription** | assessment are   | organizations,  | interoperable   |
|             | largely          | through         | electronic and  |
|             | fragmented by    | collaboration   | personal health |
|             | site of care     | with clinical   | records expands |
|             | with limited     | system vendors  | the definition  |
|             | interactions     | and end-user    | of an           |
|             | across sites.    | organizations   | "encounter" and |
|             | Electronic       | incrementally   | facilitates     |
|             | health records,  | have developed  | integration of  |
|             | where            | an expanding    | data for        |
|             | implemented,     | basic set of    | quality         |
|             | support care     | metrics,        | assessment and  |
|             | delivery but     | granularly      | improvement     |
|             | have not been    | defined to      | across sites of |
|             | designed to      | allow uniform   | care. Aligned   |
|             | facilitate       | data            | quality goals   |
|             | improvement and  | collection. The | explicitly      |
|             | assessment of    | long-term goal  | incorporate     |
|             | quality of care  | of              | individual and  |
|             | delivered across | i               | collective      |
|             | patient groups.  | nteroperability | accountability, |
|             | Clinicians and   | shows real      | and include     |
|             | provider         | promise as      | both processes  |
|             | organizations    | performance and | and outcomes.   |
|             | receive feedback | quality based   | Measures and    |
|             | reports on       | metrics have    | CDS are         |
|             | quality          | driven          | routinely       |
|             | retrospectively, | consistency in  | enhanced and    |
|             | with at least a  | granular        | refined by      |
|             | four month lag   | semantic        | examining       |
|             | from the date of | meaning for     | 'exceptions'.   |
|             | care delivery.   | those terms     | Clinical        |
|             | Adoption of EHRs | required to     | decision        |
|             | is slow, use of  | determine       | support         |
|             | clinical         | successful      | routinely       |
|             | decision support | processes and   | improves        |
|             | is limited, and  | outcomes based  | quality by      |
|             | does not address | on evidence.    | helping to      |
|             | all of the       | Certification   | ensure that the |
|             | quality          | of EHRs yields  | right care is   |
|             | objectives for   | some            | delivered to    |
|             | safety and       | improvements in | the right       |
|             | quality. There   | capabilities    | patient --      |
|             | is limited       | for quality     | every time.     |
|             | opportunity to   | improvement and | Information     |
|             | refine measures  | measurement.    | from remote     |
|             | and CDS based on |                 | sites (e.g.,    |
|             | exceptions       |                 | patients'       |
|             | (patients who do |                 | homes) and from |
|             | not "fit").      |                 | electronic      |
|             |                  |                 | communication   |
|             | Quality metrics  |                 | separate from   |
|             | are largely      |                 | electronic      |
|             | derived from     |                 | health records  |
|             | claims for       |                 | is easily       |
|             | physicians and   |                 | captured --     |
|             | medical records  |                 | securely and    |
|             | for hospitals.   |                 | privately.      |
|             |                  |                 | Quality data    |
|             | Data sources and |                 | that is         |
|             | data element     |                 | pertinent,      |
|             | definitions are  |                 | valid,          |
|             | not standardized |                 | reliable,       |
|             | within           |                 | meaningful and  |
|             | organizations    |                 | understandable  |
|             | nor across sites |                 | is available    |
|             | of care.         |                 | for consumers   |
|             |                  |                 | to enable       |
|             |                  |                 | informed        |
|             |                  |                 | choices across  |
|             |                  |                 | the care        |
|             |                  |                 | continuum       |
|             |                  |                 | (hospitals,     |
|             |                  |                 | physicians,     |
|             |                  |                 | SNF, etc.)      |
+-------------+------------------+-----------------+-----------------+
| **National  | -   No unified   | -   The         | -   National    |
| Quality     |     national     |     National    |     Goals are   |
| E           |     agenda       |     Quality     |     measured    |
| nterprise** |                  |     Forum in    |     through     |
|             | -   Measurement  |     partnership |                 |
|             |     limited by   |     with        |   comprehensive |
|             |     what is      |     measure     |     measure     |
|             |     measurable,  |     developers  |     sets that   |
|             |     rather than  |     has built   |     address all |
|             |     focused on   |     consensus   |     six IOM     |
|             |     what is      |     around a    |     aims        |
|             |     important    |     set of      |                 |
|             |     (national    |     uniform     | ```{=html}      |
|             |     priorities)  |     National    | <!-- -->        |
|             |                  |     Goals for   | ```             |
|             | -   Measure      |     quality     | -   Measures    |
|             |     development  |     that are    |     are         |
|             |     activities   |     translated  |     harmonized  |
|             |     tend to be   |     into a      |     across      |
|             |     silos and    |     Measures    |     settings    |
|             |     focus on     |     Framework   |     and level   |
|             |     provider     |     which       |     of analysis |
|             |     encounters   |     includes    |     (i.e., roll |
|             |     (e.g.,       |     common      |     up from     |
|             |     hospital     |     conventions |     provider    |
|             |     episode,     |     and         |     level to    |
|             |     physician    |     guidelines  |     health      |
|             |     visit)       |     for measure |     system to   |
|             |                  |     development |     community   |
|             | -   Many measure |     and         |     to national |
|             |     developers   |                 |     level).     |
|             |     using        |    maintenance. |                 |
|             |     different    |     Gaps in     | ```{=html}      |
|             |     standards    |     measure     | <!-- -->        |
|             |     for evidence |     development | ```             |
|             |     --grading;   |     are         | -   All         |
|             |     different    |     actively    |                 |
|             |     conventions  |     being       |    stakeholders |
|             |     and          |     filled      |     have access |
|             |     approaches   |     through the |     to          |
|             |     to           |     development |     information |
|             |     developing   |     and testing |     on "value"  |
|             |     measure      |     of new      |     (i.e., cost |
|             |                  |     measure     |     and         |
|             |  specifications, |     sets        |     outcomes    |
|             |     and having   |                 |     associated  |
|             |     different    | -   Measure     |     with        |
|             |     capabilities |     development |     different   |
|             |     in terms of  |     activities  |     medical     |
|             |     measure      |     address     |                 |
|             |     development  |     chronic     |   interventions |
|             |     and          |     care        |     and         |
|             |     maintenance. |     episodes    |     provider    |
|             |                  |     (e.g., 12   |     settings.   |
|             | -   Use of       |     month time  |                 |
|             |     clinical     |     window) and | -   Measurable  |
|             |     decision     |     address     |     outcome     |
|             |     support and  |     both care   |     improvement |
|             |     other tools  |     process and |                 |
|             |     to bring     |     patient     |    attributable |
|             |     evidence to  |     outcomes;   |     to unified, |
|             |     the point of |     and both    |     widespread  |
|             |     care is low  |     quality and |     reporting   |
|             |                  |     resource    |     and EHR use |
|             | -   Focus of     |     use.        |     with        |
|             |     m            |                 |     effective   |
|             | easurement-drive |                 |     CDS is      |
|             |     quality      |                 |     routine     |
|             |     improvement  |                 |                 |
|             |     on provider  |                 |                 |
|             |     encounters   |                 |                 |
|             |     (e.g.,       |                 |                 |
|             |     hospital     |                 |                 |
|             |     episode,     |                 |                 |
|             |     physician    |                 |                 |
|             |     visit) and   |                 |                 |
|             |     on process,  |                 |                 |
|             |     rather than  |                 |                 |
|             |     outcomes     |                 |                 |
+-------------+------------------+-----------------+-----------------+
| **          |                  |                 |                 |
| Description |                  |                 |                 |
| of Key      |                  |                 |                 |
| St          |                  |                 |                 |
| akeholders' |                  |                 |                 |
| Experience  |                  |                 |                 |
| with the    |                  |                 |                 |
| National    |                  |                 |                 |
| Quality     |                  |                 |                 |
| E           |                  |                 |                 |
| nterprise** |                  |                 |                 |
+-------------+------------------+-----------------+-----------------+
| **          | -   Some         | -   Additional  | -   National    |
| Consumers** |     interest in  |     information |     quality     |
|             |     use of       |     on cost and |     agenda      |
|             |     quality      |     patient     |     reflects    |
|             |     information  |     experience  |     patient     |
|             |     to guide     |     included in |     needs       |
|             |     decisions    |     public      |                 |
|             |     about where  |     information | -   Widespread  |
|             |     to seek care |                 |     awareness   |
|             |                  | -   Expanded    |     of national |
|             | -   Limited use  |     coverage of |     quality     |
|             |     of existing  |     providers   |     agenda      |
|             |     sources,     |     and sites   |                 |
|             |     which focus  |     of care in  | -   Routine use |
|             |     on health    |     public      |     of provider |
|             |     plan,        |     performance |     performance |
|             |     hospitals    |     reporting   |     information |
|             |     and nursing  |                 |                 |
|             |     home care    | -   Information | -   Widespread  |
|             |                  |     sources     |     use of      |
|             | -   Limited      |     more        |     consumer    |
|             |     information  |                 |     knowledge   |
|             |     on cost of   |    standardized |     sources and |
|             |     care         |     and         |     self-care   |
|             |     provided by  |     consumer    |     tools       |
|             |     insurers     |     friendly    |                 |
|             |                  |                 | -   Consumers   |
|             | ```{=html}       | -   Increasing  |     have access |
|             | <!-- -->         |     number of   |     to          |
|             | ```              |     outcome     |     counselors  |
|             | -   Existing     |     measures    |     who can     |
|             |     sources      |     meaningful  |     help them   |
|             |     generally    |     to          |     access and  |
|             |     not          |     consumers   |     interpret   |
|             |     c            |                 |     quality     |
|             | onsumer-friendly | -   Greater     |     information |
|             |                  |     awareness   |                 |
|             |                  |     of options, | -   Consumers   |
|             |                  |     evidence    |     have        |
|             |                  |     and best    |     regular     |
|             |                  |     practices   |     channels    |
|             |                  |                 |     through     |
|             |                  |                 |     which to    |
|             |                  |                 |     report      |
|             |                  |                 |     their       |
|             |                  |                 |     experience  |
|             |                  |                 |     with care   |
+-------------+------------------+-----------------+-----------------+
| **          | -   Multiple     | -   Reduced     | -   Simplified  |
| Hospitals** |     external     |     burden of   |     quality     |
|             |     reporting    |     external    |     measurement |
|             |     requirements |     reporting   |     and         |
|             |     and sets of  |     due to      |     reporting   |
|             |     metrics      |     convergence |     due to      |
|             |                  |     of metrics  |     national    |
|             |  (accreditation, |     and         |     consensus   |
|             |     state,       |     submission  |     metrics and |
|             |     Medicare,    |                 |     unified     |
|             |     other        |    requirements |     data        |
|             |     payers),     |                 |     stewardship |
|             |     although     | -   Increased   |                 |
|             |     convergence  |     reliance on | -   Where       |
|             |     on HQA       |     electronic  |     markets     |
|             |     measures is  |     data during |     support     |
|             |     accelerating |     assembly of |                 |
|             |                  |     information |    competition, |
|             | -   20% of HMOs  |     for         |     market      |
|             |     have         |     external    |                 |
|             |     introduced   |     reporting   | differentiation |
|             |     P4P programs |                 |     is based on |
|             |     for          | -   Increased   |     safety,     |
|             |     hospitals    |     ability to  |     quality,    |
|             |                  |     engage in   |     and cost    |
|             | -   Increasing   |     prospective |     performance |
|             |     demands for  |     patient     |                 |
|             |     public       |     tracking    | -   Performance |
|             |     quality      |     and quality |     information |
|             |     reporting    |     improvement |     reported    |
|             |                  |     due to      |     publicly by |
|             | -   Data for     |     incremental |     hospitals   |
|             |     measurement  |     roll-out of |     and used in |
|             |     primarily    |     inpatient   |     marketing   |
|             |     from chart   |     EHR (CPOE,  |     where       |
|             |     review       |     eMAR,       |     markets     |
|             |                  |     clinical    |     support     |
|             | -   Feedback     |                 |     competition |
|             |     reporting    |   documentation |                 |
|             |     from         |                 | -   Needs for   |
|             |     external     | -   More        |     measurement |
|             |     bodies       |                 |     and quality |
|             |     delayed by   |   institutional |     improvement |
|             |     months or    |     support for |     largely met |
|             |     quarters     |     quality     |     by EHR and  |
|             |                  |     improvement |     other       |
|             | -   Difficulty   |     and         |     network     |
|             |     achieving    |     performance |                 |
|             |     system-level |     measurement |    technologies |
|             |     improvement  |                 |                 |
|             |     due in apart | -   National    | -   CDS         |
|             |     to lack of   |                 |     routinely   |
|             |     alignment    |   certification |     available   |
|             |     between      |     process     |                 |
|             |     physicians   |     guides      | -   Rapid       |
|             |     and          |     choice of   |     diffusion   |
|             |     hospitals    |     EHR systems |     of new      |
|             |                  |     that        |     guidelines, |
|             | -   EHR adoption |     facilitate  |     metrics and |
|             |     is low and   |     quality     |     best        |
|             |     CDS          |     improvement |     practices   |
|             |                  |                 |     into EHR's  |
|             |   implementation |                 |     facilitates |
|             |     and results  |                 |     by          |
|             |     are highly   |                 |     standards   |
|             |     variable     |                 |     and         |
|             |     from site to |                 |                 |
|             |     site         |                 |    distribution |
|             |                  |                 |     services    |
|             |                  |                 |                 |
|             |                  |                 | -               |
|             |                  |                 |   Certification |
|             |                  |                 |     of HIT      |
|             |                  |                 |     systems now |
|             |                  |                 |     based on    |
|             |                  |                 |     performance |
|             |                  |                 |     and         |
|             |                  |                 |     outcomes in |
|             |                  |                 |     the field   |
+-------------+------------------+-----------------+-----------------+
| **Physician | -   Increasing   | -   Simplified  | -   Simplified  |
| s/Physician |     demands for  |     quality     |     quality     |
| Practices** |     public       |     measurement |     measurement |
|             |     quality      |     and         |     and         |
|             |     reporting    |     reporting   |     reporting   |
|             |                  |     due to      |     due to      |
|             | -   Multiple     |     national    |     national    |
|             |     sets of      |     consensus   |     consensus   |
|             |                  |     metrics     |     metrics and |
|             |   evidence-based |                 |     unified     |
|             |     guidelines   | -   Reduced     |     data        |
|             |     reflected in |     burden of   |     stewardship |
|             |     external     |     external    |                 |
|             |     metrics      |     reporting   | -   Focus on    |
|             |                  |     due to      |     internal    |
|             | -   Feedback     |     convergence |     quality     |
|             |     reporting    |     of metrics  |     improvement |
|             |     based on     |     and         |     due to      |
|             |     claims not   |     submission  |     national    |
|             |     viewed as    |                 |     consensus   |
|             |     accurate or  |    requirements |     on quality  |
|             |     clinically   |                 |     improvement |
|             |     valid        | -   Increased   |     priorities  |
|             |                  |     adoption of |                 |
|             | -   Reliance on  |     EHRs        | -   Market      |
|             |     medical      |     improving   |                 |
|             |     record       |     prospective | differentiation |
|             |     information  |     patient     |     based on    |
|             |     in emerging  |     tracking    |     safety,     |
|             |     metrics      |     and quality |     quality,    |
|             |     poses        |                 |     and cost    |
|             |     unmanageable |    improvement, |     performance |
|             |                  |     as well as  |                 |
|             |   administrative |     quality     | -   Effective   |
|             |     burden of    |     reporting   |     CDS         |
|             |     chart review |                 |     routinely   |
|             |                  |                 |     available   |
|             |                  |                 |                 |
|             |                  |                 | -   Guidelines  |
|             |                  |                 |     and metrics |
|             |                  |                 |     effectively |
|             |                  |                 |     translated  |
|             |                  |                 |     into EHR    |
|             |                  |                 |     workflow    |
|             |                  |                 |                 |
|             |                  |                 | -   Performance |
|             |                  |                 |     information |
|             |                  |                 |     reported    |
|             |                  |                 |     publicly by |
|             |                  |                 |     physi       |
|             |                  |                 | cians/physician |
|             |                  |                 |     practices   |
|             |                  |                 |     and used in |
|             |                  |                 |     marketing   |
|             |                  |                 |                 |
|             |                  |                 | -   Needs for   |
|             |                  |                 |     measurement |
|             |                  |                 |     and quality |
|             |                  |                 |     improvement |
|             |                  |                 |     largely met |
|             |                  |                 |     by EHR and  |
|             |                  |                 |     other       |
|             |                  |                 |     network     |
|             |                  |                 |                 |
|             |                  |                 |    technologies |
|             |                  |                 |                 |
|             |                  |                 | -   Clinicians  |
|             |                  |                 |     are engaged |
|             |                  |                 |     and         |
|             |                  |                 |     motivated   |
|             |                  |                 |     to improve  |
|             |                  |                 |                 |
|             |                  |                 | -   Networks of |
|             |                  |                 |                 |
|             |                  |                 |   practitioners |
|             |                  |                 |     communicate |
|             |                  |                 |     easily with |
|             |                  |                 |     each other  |
|             |                  |                 |     to provide  |
|             |                  |                 |     coordinated |
|             |                  |                 |     care        |
+-------------+------------------+-----------------+-----------------+
| **          | -   Interest in  | -   Consumer    | -   National    |
| Employers** |     providing    |     engagement  |     consensus   |
|             |     performance  |     strategies  |     quality     |
|             |     information  |     are more    |     goals and   |
|             |     to employees |     mature and  |     standards   |
|             |     to inform    |     are tied to |     for quality |
|             |     decisions    |                 |     performance |
|             |     about where  |    transparency |     reporting   |
|             |     to seek care |     of price    |     provide     |
|             |                  |     and quality |                 |
|             | -   Beginning to |                 |   comprehensive |
|             |     adopt new    | -   Increasing  |     basis for   |
|             |     models for   |     promotion   |     employee    |
|             |     health       |     of patient  |     awareness   |
|             |     insurance    |     empowerment |     and         |
|             |     coverage     |                 |     incentives  |
|             |     that provide | -   Increased   |                 |
|             |     incentives   |     linking of  | -   Choice of   |
|             |     to employees |     payment to  |     health      |
|             |     to become    |     performance |     plans,      |
|             |     more         |                 |     physicians, |
|             |     discerning   | -               |     hospitals   |
|             |     consumers of |    Increasingly |     enhanced by |
|             |     health care  |     direct      |                 |
|             |     services     |                 |    availability |
|             |                  |    relationship |     of          |
|             | -   Increasingly |     between     |     performance |
|             |     investing in |     healthcare  |     data        |
|             |     wellness and |     reporting,  |                 |
|             |     disease      |     pay-        |                 |
|             |     management   | for-performance |                 |
|             |     programs to  |     and         |                 |
|             |     improve      |     employee    |                 |
|             |     health       |                 |                 |
|             |     management   |    productivity |                 |
|             |     and reduce   |     and         |                 |
|             |     costs        |     healthcare  |                 |
|             |                  |     costs       |                 |
|             | -   Double       |                 |                 |
|             |     penalty from | -   Increasing  |                 |
|             |     poor or      |     ability to  |                 |
|             |     inconsistent |     manage      |                 |
|             |     quality-     |     shared cost |                 |
|             |     increased    |     programs    |                 |
|             |     healthcare   |     with        |                 |
|             |     spending and |     employees   |                 |
|             |     reduced      |     due to      |                 |
|             |     worker       |                 |                 |
|             |     productivity |    availability |                 |
|             |                  |     of          |                 |
|             | -   Seeking ways |     valuable,   |                 |
|             |     to manage    |                 |                 |
|             |     costs of     |  understandable |                 |
|             |     provision of |     and         |                 |
|             |     healthcare   |     applicable  |                 |
|             |     coverage to  |     healthcare  |                 |
|             |     employees    |     quality     |                 |
|             |                  |     performance |                 |
|             |                  |     reporting   |                 |
+-------------+------------------+-----------------+-----------------+
| **Payers**  | -   Specifying   | -   Consumer    | -               |
|             |     quality      |     engagement  |   Significantly |
|             |     expectations |     strategies  |     reduced     |
|             |     and          |     are more    |                 |
|             |     reporting    |     mature and  |  administrative |
|             |     through      |     are tied to |     burden of   |
|             |     contracts    |                 |     performance |
|             |                  |    transparency |     measurement |
|             | -   Measuring    |     of price    |     due to      |
|             |     quality      |     and quality |     adoption of |
|             |     performance  |                 |     national    |
|             |     largely      | -   Promote     |     consensus   |
|             |     through      |     patient     |     metrics and |
|             |     claims       |     empowerment |     unified     |
|             |     because      |                 |     data        |
|             |     electronic   | -   Increased   |     stewardship |
|             |     clinical     |     linking of  |                 |
|             |     information  |                 | -               |
|             |     generally    |   "performance" |   Significantly |
|             |     lacking.     |     to payment  |     reduced     |
|             |     Performance  |                 |                 |
|             |     information  | -   Clinical    |  administrative |
|             |     is           |     data from   |     burden of   |
|             |     insufficient |     EHR's now   |     performance |
|             |     to determine |     available   |     measurement |
|             |     true under-  |     to support  |     due to      |
|             |     and          |     more        |     adoption of |
|             |                  |     precise,    |     national    |
|             | over-utilization |     accurate,   |     consensus   |
|             |     of services  |     predictive  |     metrics and |
|             |     due to       |     metrics     |     unified     |
|             |     missing      |                 |     data        |
|             |     clinical     | -   Increasing  |     stewardship |
|             |     context      |     use of      |                 |
|             |     information. |     structural  | -               |
|             |     Frustrated   |     measures in |   Comprehensive |
|             |     by inability |     external    |     basis for   |
|             |     to           |     reporting   |     quality     |
|             |     accurately   |     and         |     performance |
|             |     assess       |     financial   |     incentives  |
|             |     misuse even  |     incentives  |     provided by |
|             |     with         |                 |     national    |
|             |     expensive    | -   Consensus   |     consensus   |
|             |     hybrid       |     and         |     quality     |
|             |                  |                 |     goals and   |
|             |    methodologies | standardization |     standards   |
|             |     (e.g., chart |     of quality  |     for quality |
|             |     reviews).    |     and         |     performance |
|             |                  |     performance |     reporting   |
|             | -   Consumer     |     measures    |                 |
|             |     engagement   |     (           | -   More of     |
|             |     initiatives  | patient-centric |     healthcare  |
|             |     are emerging |     and         |     spending    |
|             |                  |     pr          |     can be      |
|             | -   Select plans | ovider-centric) |     per         |
|             |     are          |     allows      | formance-based, |
|             |     incenting    |     payers to   |     due to      |
|             |     health IT    |     explore     |     better      |
|             |     adoption     |     incentive   |     reliability |
|             |     based on     |     programs to |     of metrics  |
|             |     structural   |     providers   |     and better  |
|             |     measures     |     and to      |     tools to    |
|             |     (CPOE, use   |     members     |     improve     |
|             |     of EMR or    |     (insured    |     quality     |
|             |     registry)    |     clients)    |                 |
|             |                  |     based on    |                 |
|             | -   Broadening   |     outcomes    |                 |
|             |     traditional  |                 |                 |
|             |     disease      | -               |                 |
|             |     management   |  Administrative |                 |
|             |     programs to  |     burden      |                 |
|             |     include      |     remains     |                 |
|             |     wellness and |     high but is |                 |
|             |     reach more   |     more        |                 |
|             |     members, but |     manageable  |                 |
|             |                  |     as access   |                 |
|             |    determination |     to data is  |                 |
|             |     of true      |     enhanced by |                 |
|             |     functional   |     adoption of |                 |
|             |     outcomes     |     ambulatory  |                 |
|             |     remains      |     EHRs        |                 |
|             |     cumbersome   |                 |                 |
|             |     and          |                 |                 |
|             |     problematic  |                 |                 |
+-------------+------------------+-----------------+-----------------+
| **Pol       | -   Executive    | -   Improve     | -   Health care |
| icymakers** |     and          |     quality of  |     policy      |
|             |     legislative  |     care        |     unified     |
|             |     pressure to  |     through     |     around the  |
|             |     increase     |     ready       |     national    |
|             |     transparency |     access to   |     quality     |
|             |     in HIT       |     complete    |     agenda and  |
|             |     standards    |     and         |                 |
|             |     adoption,    |     accurate    |   incorporating |
|             |     quality      |     quality     |     gaps        |
|             |     measures,    |     data        |     identified  |
|             |     consumer     |                 |     in the      |
|             |     cost and     | -   Link        |     National    |
|             |     incentive    |                 |     Quality     |
|             |     systems      |   "performance" |     Report      |
|             |                  |     to payment  |                 |
|             | -   Hospital pay |                 | -   Quality     |
|             |     for          | -   Allow for   |     m           |
|             |     performance  |     national    | easure-focused, |
|             |     program      |     and         |     incremental |
|             |     under        |     regional    |     semantic    |
|             |     development  |     comparison  |     i           |
|             |                  |     of          | nteroperability |
|             | -   Physician    |     providers   |     development |
|             |     payment      |                 |     allows for  |
|             |     reform       | -               |     more facile |
|             |     challenged   |   Certification |     p           |
|             |     by           |     Commission  | opulation-based |
|             |     decreasing   |                 |     outcome     |
|             |     physician    |    requirements |     reporting   |
|             |     revenues,    |     call for    |                 |
|             |     limited data |     robust CDS  | -   Policy      |
|             |     and          |     to be       |     decisions   |
|             |     insufficient |     present in  |     can be      |
|             |     metrics      |     systems     |     reviewed    |
|             |                  |                 |     annually    |
|             | -   Better data  | -   CMS becomes |     based on    |
|             |     is needed to |     more        |     p           |
|             |     inform       |     involved in | opulation-based |
|             |     policy       |     pay-        |     reporting   |
|             |     decisions    | for-performance |     and         |
|             |     regarding    |     and related |     analysis of |
|             |     funding of   |     programs,   |     outcomes    |
|             |     existing and |     including   |     enabling    |
|             |     new health   |     support for |                 |
|             |     programs and |     healthcare  |  modifications, |
|             |     extension of |     IT          |                 |
|             |     policies to  |                 |    enhancements |
|             |     broader      | -   Effective   |     or          |
|             |     populations. |     legal       |                 |
|             |                  |     protections | discontinuation |
|             | -   Outcomes of  |     remove      |     of policies |
|             |     policy       |     concerns    |     as          |
|             |     decisions    |     about using |     appropriate |
|             |     (i.e.,       |     CDS         |                 |
|             |                  |                 |                 |
|             |   effectiveness) | -   Increased   |                 |
|             |     are often    |     utilization |                 |
|             |     not measured |     and         |                 |
|             |                  |     reporting   |                 |
|             |                  |     from        |                 |
|             |                  |     ambulatory  |                 |
|             |                  |     and         |                 |
|             |                  |                 |                 |
|             |                  |  facility-based |                 |
|             |                  |     EHRs allows |                 |
|             |                  |     for         |                 |
|             |                  |     analysis of |                 |
|             |                  |     populations |                 |
|             |                  |     to support  |                 |
|             |                  |     policy      |                 |
|             |                  |     decisions   |                 |
|             |                  |                 |                 |
|             |                  | -   Some        |                 |
|             |                  |     success in  |                 |
|             |                  |     measuring   |                 |
|             |                  |     outcomes of |                 |
|             |                  |     policy      |                 |
|             |                  |     decisions   |                 |
|             |                  |     from        |                 |
|             |                  |     p           |                 |
|             |                  | opulation-based |                 |
|             |                  |     reporting   |                 |
+-------------+------------------+-----------------+-----------------+
| **Ac        | -   Individual   | -   Additional  | -   Robust      |
| creditors** |     accrediting  |                 |     measurement |
|             |                  |  evidence-based |     sets based  |
|             |    organizations |     measures    |     on robust   |
|             |     use separate |     available   |     evidence    |
|             |     sets of      |     to be used  |     base        |
|             |     performance  |     in          |                 |
|             |     measures and |     evaluation  | -   Continuous  |
|             |     different    |                 |     evaluation  |
|             |     approaches   | -   Increasing  |     based on    |
|             |     to           |     reliance on |     robust,     |
|             |     measurement  |     performance |     easily      |
|             |     and          |     measurement |     accessible  |
|             |     reporting as |     in          |     data        |
|             |     part of      |                 |                 |
|             |                  |   accreditation |                 |
|             |    accreditation |                 |                 |
|             |                  |                 |                 |
|             | -   Ability to   |                 |                 |
|             |     measure      |                 |                 |
|             |     severely     |                 |                 |
|             |     limited by   |                 |                 |
|             |     data         |                 |                 |
|             |                  |                 |                 |
|             |    accessibility |                 |                 |
+-------------+------------------+-----------------+-----------------+
| >           | -   Many gaps in | -   Evidence    | -   Guideline   |
|  **Research |     evidence     |     gaps        |     developers  |
| >           |     base         |     identified  |     and         |
| Community** |     pertaining   |     through     |     clinical    |
|             |     to important |     National    |     researchers |
|             |     aspects of   |                 |     collect     |
|             |     care.        |   Priority/Goal |     performance |
|             |     Evidence not |     Setting     |     measurement |
|             |     specific     |     process and |     data and    |
|             |     enough to    |     feedback    |     refine      |
|             |     support the  |     loop from   |     evidence    |
|             |     development  |     measure     |     base and    |
|             |     of practice  |     developers  |     practice    |
|             |     guidelines   |     and         |     guidelines  |
|             |     that can be  |                 |     in near     |
|             |                  |   implementers. |     real time.  |
|             |  operationalized |                 |                 |
|             |     into         | -   NIH         |                 |
|             |     performance  |     addresses   |                 |
|             |     measures or  |     information |                 |
|             |     EHR          |     gaps in     |                 |
|             |     d            |     research    |                 |
|             | ecision-support. |     agenda      |                 |
|             |                  |     setting     |                 |
|             | -   New evidence |     process and |                 |
|             |     fails to get |     funding     |                 |
|             |     translated   |     decisions.  |                 |
|             |     into         |                 |                 |
|             |     practice     | -   More        |                 |
|             |     guidelines   |                 |                 |
|             |     in a timely  |    well-defined |                 |
|             |     fashion      |     and         |                 |
|             |     (often       |     efficient   |                 |
|             |     decades)     |     path for    |                 |
|             |                  |     translating |                 |
|             |                  |     evidence to |                 |
|             |                  |     practice    |                 |
|             |                  |     guidelines  |                 |
|             |                  |     and         |                 |
|             |                  |     guidelines  |                 |
|             |                  |     into        |                 |
|             |                  |     performance |                 |
|             |                  |     measures.   |                 |
+-------------+------------------+-----------------+-----------------+
| **Defining  |                  |                 |                 |
| Charac      |                  |                 |                 |
| teristics** |                  |                 |                 |
| **or        |                  |                 |                 |
| Attributes  |                  |                 |                 |
| of the      |                  |                 |                 |
| Health Care |                  |                 |                 |
| System with |                  |                 |                 |
| Respect to  |                  |                 |                 |
| the Quality |                  |                 |                 |
| E           |                  |                 |                 |
| nterprise** |                  |                 |                 |
+-------------+------------------+-----------------+-----------------+
| **Receiving | -   Patients     | -   Increasing  | -   Patient     |
| Care**      |     often        |     adoption of |     expectation |
|             |     required to  |     EHRs        |     that        |
|             |     supply       |     improving   |     providers   |
|             |     medical      |     access to   |     are         |
|             |     record       |     medical     |     supported   |
|             |     information  |     record      |     by EHRs     |
|             |     because of   |     information |                 |
|             |     site- and    |     when        | -   Public      |
|             |                  |     seeking     |     awareness   |
|             |   venue-specific |     care        |     that EHRs   |
|             |     medical      |                 |     facilitate  |
|             |     records      | -   Increasing  |     delivering  |
|             |                  |     adoption of |     safer care  |
|             | -   Public       |     PHRs and    |     and health  |
|             |     increasingly |     broader use |     management  |
|             |     aware of     |     of clinical |     in line     |
|             |     gaps in care |     messaging   |     with        |
|             |     and safety   |     help        |     national    |
|             |     issues for   |     patients    |     quality     |
|             |     themselves   |     become more |     agenda      |
|             |     and family   |     informed    |                 |
|             |     members      |     and engaged | -   Widespread  |
|             |                  |     in their    |     use of PHRs |
|             | ```{=html}       |     care        |     and         |
|             | <!-- -->         |                 |     clinical    |
|             | ```              | -   Increasing  |     messaging,  |
|             | -   Increasing   |                 |     providing   |
|             |     interest in  |    availability |     non-        |
|             |     greater      |     of          | encounter-based |
|             |                  |     con         |     access to   |
|             |    participation | dition-specific |     information |
|             |     in decisions |     tools help  |     and support |
|             |     relating to  |     patients    |     when it is  |
|             |     health and   |     with        |     needed      |
|             |     care         |     chronic     |                 |
|             |     management,  |     conditions  | -   Tailored    |
|             |     but          |                 |     self-care   |
|             |     difficult to |                 |     programs    |
|             |     find         |                 |     and         |
|             |     information  |                 |     guidelines  |
|             |     about best   |                 |     are more    |
|             |     courses of   |                 |     available   |
|             |     action to    |                 |                 |
|             |     take         |                 |                 |
|             |                  |                 |                 |
|             | -   Very early   |                 |                 |
|             |     adoption of  |                 |                 |
|             |     PHRs to      |                 |                 |
|             |     share        |                 |                 |
|             |     medical      |                 |                 |
|             |     record       |                 |                 |
|             |     information  |                 |                 |
|             |     with         |                 |                 |
|             |     patients,    |                 |                 |
|             |     provide easy |                 |                 |
|             |     access to    |                 |                 |
|             |     health       |                 |                 |
|             |     information  |                 |                 |
|             |     and          |                 |                 |
|             |                  |                 |                 |
|             |  self-management |                 |                 |
|             |     resources,   |                 |                 |
|             |     and enable   |                 |                 |
|             |                  |                 |                 |
|             |    non-encounter |                 |                 |
|             |     access to    |                 |                 |
|             |     information  |                 |                 |
|             |     and advice   |                 |                 |
+-------------+------------------+-----------------+-----------------+
| *           | -   Difficulty   | -   Increasing  | -   EHR support |
| *Delivering |     assembling   |     adoption of |     at the      |
| Enco        |                  |     EHRs that   |     point of    |
| unter-Based |    comprehensive |     are         |     care is     |
| Care**      |     view of      |                 |     common      |
|             |     patient's    |   interoperable |     practice    |
|             |     health and   |     with PHRs   |                 |
|             |     health care  |     reducing    | -   Point of    |
|             |     needs due to |     reliance on |     care        |
|             |     paper        |     paper       |     prompting   |
|             |     medical      |     medical     |     and other   |
|             |     records and  |     records     |                 |
|             |     siloed data  |                 |   interventions |
|             |     storage      | -   Increasing  |     addressing  |
|             |                  |     use of EHRs |     wide range  |
|             | -   Limited time |     for care    |     of          |
|             |     to deal with |                 |     con         |
|             |     other than   |   documentation | dition-specific |
|             |     acute        |     and         |     guidelines  |
|             |     problems     |     improved    |     and patient |
|             |     when         |     capture of  |     safety      |
|             |     patients     |     information |                 |
|             |     present for  |     needed for  | -               |
|             |     care         |     care        |    Distribution |
|             |                  |     management  |     systems     |
|             |    (productivity |     and quality |     keep EHR\'s |
|             |     pressures)   |     improvement |     up-to-date  |
|             |                  |                 |     with        |
|             | -   Largely      | -   CDS tools   |                 |
|             |     manual       |     embedded in |   best-practice |
|             |                  |     HIT are     |     CDS based   |
|             |   documentation, |     beginning   |     on latest   |
|             |     not geared   |     to drive    |     knowledge   |
|             |     to the       |     measurably  |                 |
|             |     specifics    |     improved    | -   Data from   |
|             |     needed for   |                 |                 |
|             |     patient      | encounter-based |   interoperable |
|             |     tracking,    |     care        |     EHR\'s is   |
|             |     quality      |     processes   |     available   |
|             |     improvement, |     and         |     to the      |
|             |     measurement, |     outcomes on |     research    |
|             |     and          |     a           |     enterprise  |
|             |     reporting    |     widespread  |     to better   |
|             |                  |     basis       |     assess and  |
|             | -   Limited      |                 |     prioritize  |
|             |     assistance   |                 |     national    |
|             |     at the point |                 |     quality     |
|             |     of care in   |                 |     metrics and |
|             |     identifying  |                 |     guidelines  |
|             |     and closing  |                 |                 |
|             |                  |                 |                 |
|             | patient-specific |                 |                 |
|             |     gaps in care |                 |                 |
|             |     as indicated |                 |                 |
|             |     by           |                 |                 |
|             |                  |                 |                 |
|             |   evidence-based |                 |                 |
|             |     guidelines   |                 |                 |
+-------------+------------------+-----------------+-----------------+
| **Managing  | -   Difficulty   | -   Increasing  | -   Reduced     |
| Health of   |     tracking     |     adoption of |     gaps in     |
| Defined     |     patients for |     EHRs        |     care for    |
| Po          |     needed       |     reducing    |     population  |
| pulations** |     follow-up    |     reliance on |     due to      |
|             |     due to       |     paper       |     improved    |
|             |     limitations  |     medical     |                 |
|             |     of paper     |     records     |   EHR-supported |
|             |     medical      |                 |     care        |
|             |     records      | -   Increasing  |                 |
|             |                  |     use of EHR  | -               |
|             | -   Difficulty   |     for care    |    Availability |
|             |     identifying  |                 |     of patient  |
|             |     all patients |   documentation |     lists and   |
|             |     with a       |     and         |                 |
|             |     particular   |     improved    |  communications |
|             |     condition    |     capture of  |     from EHR to |
|             |     and          |     information |     support     |
|             |     assessing    |     needed for  |     outreach to |
|             |     and closing  |     care        |     patients    |
|             |     gaps in care |     management  |     with gaps   |
|             |     according to |     and quality |     in care     |
|             |                  |     improvement |                 |
|             |   evidence-based |                 | -   Ability to  |
|             |     guidelines   | -   Increasing  |     send        |
|             |                  |     adoption of |     reminders   |
|             |                  |     PHRs        |     and other   |
|             |                  |     increasing  |                 |
|             |                  |     patient     |  communications |
|             |                  |     awareness   |     to many     |
|             |                  |     and         |     patients    |
|             |                  |     involvement |     via secure  |
|             |                  |     in health   |     clinical    |
|             |                  |     management  |     messaging;  |
|             |                  |                 |                 |
|             |                  | -   CDS,        |   incorporation |
|             |                  |     including   |     of CDS in   |
|             |                  |     hea         |     EHRs allows |
|             |                  | lth-maintenance |     for         |
|             |                  |                 |     appropriate |
|             |                  |  interventions, |     care to be  |
|             |                  |     facilitates |     provided    |
|             |                  |     individual  |     directly    |
|             |                  |     and group   |     within      |
|             |                  |     quality     |     encounter   |
|             |                  |     improvement |     workflow,   |
|             |                  |                 |     with        |
|             |                  | -   Patients    |     limited     |
|             |                  |     with        |     requirement |
|             |                  |     general and |     for         |
|             |                  |     urgent      |     a           |
|             |                  |     needs can   | lerts/reminders |
|             |                  |     be          |                 |
|             |                  |     identified  | -   Improved    |
|             |                  |     easily      |     systems     |
|             |                  |                 |     facilitate  |
|             |                  | -   Care        |     better,     |
|             |                  |     management  |                 |
|             |                  |                 | non-conflicting |
|             |                  |  infrastructure |     care of     |
|             |                  |     services    |     patients    |
|             |                  |     improve     |     with        |
|             |                  |     ability of  |     multiple    |
|             |                  |     small       |     chronic     |
|             |                  |     practices   |     problems    |
|             |                  |     to          |                 |
|             |                  |     participate |                 |
+-------------+------------------+-----------------+-----------------+
| **C         | -   Site- and    | -   Referral    | -   Widespread  |
| oordination |                  |     information |     adoption of |
| of Care**   |   venue-specific |     systems     |                 |
|             |     medical      |     facilitate  |   interoperable |
|             |     records      |     transfer of |     EHRs and    |
|             |     (paper and   |     critical    |     PHRs        |
|             |     electronic)  |     information |     enables     |
|             |                  |     needed for  |     information |
|             | -   Manual       |     care        |     sharing     |
|             |     processes    |                 |     across      |
|             |     required to  |    coordination |     sites and   |
|             |     communicate  |     and         |     settings of |
|             |     relevant     |     continuity  |     care        |
|             |     information  |                 |                 |
|             |                  | -   Quality     | -               |
|             | -   Most patient |     metrics     | Multi-practice, |
|             |     hand-offs    |     begin to    |     coordinated |
|             |     accomplished |     include     |     guidelines  |
|             |     without      |                 |     and         |
|             |     continuity   |  multi-practice |     protocols   |
|             |     of           |     care        |     are widely  |
|             |     information  |     processes   |     used        |
|             |     to enable    |                 |                 |
|             |     continuity   | -   Payment     | -   Referral    |
|             |     of care      |     programs    |     information |
|             |                  |     begin to    |     systems     |
|             |                  |     reward      |     indicate    |
|             |                  |     effectivene |     performance |
|             |                  | ss/coordination |     of          |
|             |                  |     of care     |     potential   |
|             |                  |                 |     consultants |
|             |                  | -   Increasing  |                 |
|             |                  |                 |                 |
|             |                  |   incorporation |                 |
|             |                  |     of          |                 |
|             |                  |                 |                 |
|             |                  | patient-centric |                 |
|             |                  |     medical     |                 |
|             |                  |     records     |                 |
|             |                  |     with        |                 |
|             |                  |     role-based  |                 |
|             |                  |     views of    |                 |
|             |                  |     the same    |                 |
|             |                  |     information |                 |
|             |                  |     allows for  |                 |
|             |                  |     more        |                 |
|             |                  |     effective   |                 |
|             |                  |                 |                 |
|             |                  |    coordination |                 |
|             |                  |     of care     |                 |
+-------------+------------------+-----------------+-----------------+
| **Improving | -   QI driven by | -   Data        | -   Real-time   |
| Quality**   |     required     |     collection  |     access to   |
|             |     external     |     for HQA/AQA |     internal    |
|             |     reporting    |     quality     |     reporting   |
|             |     yet          |     measures    |     providing   |
|             |     constrained  |     are largely |                 |
|             |     by the       |     automated   |    user-defined |
|             |     intensity of |     through     |     views of    |
|             |     data         |     EHR\'s      |     quality     |
|             |     collection   |                 |     performance |
|             |     for those    | -   Event       |                 |
|             |     efforts      |     detectors   | -   Ability to  |
|             |                  |     in EHR\'s   |     integrate   |
|             | -   Too much     |     spot        |     p           |
|             |     reliance on  |     significant | atient-specific |
|             |                  |     variances   |     care and    |
|             |  labor-intensive |     and hazards |     safety      |
|             |     chart review |                 |                 |
|             |     for          | -   Control     | recommendations |
|             |     performance  |     charts and  |     into        |
|             |     measurement  |     scorecards  |                 |
|             |     a limiting   |     are widely  |   EHR-supported |
|             |     factor in    |     used        |     tasks and   |
|             |     moving       |                 |     workflow    |
|             |     forward with | -   Data        |                 |
|             |     quality      |     standards   | -   CDS is      |
|             |     improvement  |     exist for   |     selectively |
|             |                  |     common data |                 |
|             | -   Limited      |     elements    |    concentrated |
|             |     ability to   |     required    |     toward      |
|             |     bring care   |     for quality |     hig         |
|             |                  |     reporting   | hest-frequency/ |
|             |  recommendations |                 |     h           |
|             |     to the point | -   Improved    | ighest-severity |
|             |     of care      |     CDS efforts |     quality     |
|             |                  |     allow for   |     issues      |
|             |                  |     automated   |                 |
|             |                  |     collection  | -   Reporting   |
|             |                  |     of          |     can be      |
|             |                  |     adherence,  |     enabled at  |
|             |                  |                 |     the         |
|             |                  |  non-adherence, |     individual  |
|             |                  |     and         |     patient     |
|             |                  |     exclusion   |     level as    |
|             |                  |     criteria    |     part of the |
|             |                  |                 |     decision    |
|             |                  |                 |     making      |
|             |                  |                 |     process     |
|             |                  |                 |     (i.e.,      |
|             |                  |                 |     probability |
|             |                  |                 |     of expected |
|             |                  |                 |     outcome     |
|             |                  |                 |     based on    |
|             |                  |                 |     individual  |
|             |                  |                 |     treatment   |
|             |                  |                 |     options     |
|             |                  |                 |     before the  |
|             |                  |                 |     options are |
|             |                  |                 |     selected)   |
+-------------+------------------+-----------------+-----------------+
| **Measuring | -   A separate,  | -   Quality     | -   Data        |
| and         |                  |     reporting   |     collection  |
| Reporting   |  labor-intensive |     is largely  |     for quality |
| Quality**   |     process      |     supported   |     reporting   |
|             |     required for |     by existing |     is a        |
|             |     quality      |     health      |     natural     |
|             |     reporting    |     information |     byproduct   |
|             |                  |     technology  |     of care     |
|             | -   Need to      |                 |                 |
|             |     respond to   | -   All         | -   Feedback is |
|             |     numerous     |                 |     provided in |
|             |     requests for |    stakeholders |     real or     |
|             |     measurement  |     have a      |     near-real   |
|             |     with         |     robust set  |     time        |
|             |     different    |     of          |                 |
|             |     targets for  |                 | -   Quality     |
|             |     measurement  |    standardized |     data        |
|             |     and          |     quality     |     standards   |
|             |                  |     measures to |     and data    |
|             |   specifications |     use         |     stewardship |
|             |     for metrics  |                 |     services    |
|             |     and          | -   EHRs        |     improve     |
|             |     reporting    |                 |     efficiency  |
|             |                  |    increasingly |     of          |
|             |                  |     support     |                 |
|             |                  |     data        |   participation |
|             |                  |     capture and |     in multiple |
|             |                  |     reporting   |     quality     |
|             |                  |     for         |     reporting   |
|             |                  |     consensus   |     programs    |
|             |                  |     measures    |                 |
|             |                  |                 | -   Common      |
|             |                  |                 |     services    |
|             |                  |                 |     allow small |
|             |                  |                 |     practices   |
|             |                  |                 |     to          |
|             |                  |                 |     participate |
|             |                  |                 |     more        |
|             |                  |                 |     effectively |
|             |                  |                 |                 |
|             |                  |                 | -   Physician   |
|             |                  |                 |                 |
|             |                  |                 |   certification |
|             |                  |                 |     and         |
|             |                  |                 |                 |
|             |                  |                 |   accreditation |
|             |                  |                 |     is partly   |
|             |                  |                 |     based on    |
|             |                  |                 |     quality     |
|             |                  |                 |     reporting   |
|             |                  |                 |                 |
|             |                  |                 | -   Metrics     |
|             |                  |                 |     expand to   |
|             |                  |                 |     more        |
|             |                  |                 |     specialty   |
|             |                  |                 |     care        |
|             |                  |                 |     settings    |
+-------------+------------------+-----------------+-----------------+
| **Reim      | -   The payment  | -   Pay for     | -   Payment     |
| bursement** |     system is    |     performance |     reform      |
|             |     largely      |     strategies  |     exists      |
|             |     driven by    |     have        |     where       |
|             |                  |     evolved     |     incentives  |
|             |    reimbursement |     from        |     are         |
|             |     for          |     rewarding   |     aligned.    |
|             |     utilization  |                 |     Provider    |
|             |     of services, |    high-quality |                 |
|             |     regardless   |     clinical    |   organizations |
|             |     of patient   |     care to     |     are         |
|             |     outcome      |     also        |     continually |
|             |                  |     rewarding   |     improving.  |
|             | -   Pay for      |                 |     Consumers   |
|             |     performance  | patient-focused |     recognize   |
|             |     pilots and   |     care and    |     value       |
|             |     programs are |     efficiency  |                 |
|             |     increasing   |                 | -   Financial   |
|             |     in number    | -   Savings in  |     incentives  |
|             |     but studies  |                 |     to promote  |
|             |     of           |  implementation |     higher      |
|             |                  |     and         |     levels of   |
|             |    effectiveness |     reporting   |     quality     |
|             |     are mixed    |     costs have  |     across      |
|             |                  |     reached a   |     diverse     |
|             | -   The market   |     break-even  |     heath care  |
|             |     perceives    |     point, with |     settings    |
|             |     the cost of  |     some        |     are used to |
|             |     quality      |     facilities  |     improve the |
|             |     reporting to |     finding a   |     current     |
|             |     be higher    |     true return |     system      |
|             |     than the     |     on          |                 |
|             |     benefit of   |     investment, |                 |
|             |     incentives,  |     while       |                 |
|             |     but          |     allowing    |                 |
|             |     generally    |                 |                 |
|             |     supports     |    improvements |                 |
|             |     movement     |     in process  |                 |
|             |     toward       |     to enhance  |                 |
|             |     payment      |     quality     |                 |
|             |     based on     |     outcomes    |                 |
|             |     value        |     and improve |                 |
|             |                  |     pay for     |                 |
|             |                  |     performance |                 |
|             |                  |                 |                 |
|             |                  | reimbursements. |                 |
|             |                  |     Quality     |                 |
|             |                  |     metrics and |                 |
|             |                  |     semantic    |                 |
|             |                  |     i           |                 |
|             |                  | nteroperability |                 |
|             |                  |     have begun  |                 |
|             |                  |     to succeed  |                 |
|             |                  |     in          |                 |
|             |                  |     providing   |                 |
|             |                  |                 |                 |
|             |                  | cross-continuum |                 |
|             |                  |     care        |                 |
|             |                  |     management  |                 |
|             |                  |     process     |                 |
|             |                  |                 |                 |
|             |                  |   efficiencies. |                 |
|             |                  |     Population  |                 |
|             |                  |                 |                 |
|             |                  |  health-related |                 |
|             |                  |                 |                 |
|             |                  |    measurements |                 |
|             |                  |     are within  |                 |
|             |                  |     reach       |                 |
|             |                  |                 |                 |
|             |                  | -   Incentives  |                 |
|             |                  |     are able to |                 |
|             |                  |     begin to    |                 |
|             |                  |     address     |                 |
|             |                  |     quality     |                 |
|             |                  |     outcome     |                 |
|             |                  |     measures,   |                 |
|             |                  |     not solely  |                 |
|             |                  |     process     |                 |
|             |                  |     measures.   |                 |
|             |                  |     Measures    |                 |
|             |                  |     remain      |                 |
|             |                  |     somewhat    |                 |
|             |                  |     s           |                 |
|             |                  | etting-specific |                 |
|             |                  |                 |                 |
|             |                  | -   Easier,     |                 |
|             |                  |     more        |                 |
|             |                  |     consistent  |                 |
|             |                  |     reporting   |                 |
|             |                  |     leads to    |                 |
|             |                  |     more        |                 |
|             |                  |     reliable    |                 |
|             |                  |     performance |                 |
|             |                  |     measures    |                 |
|             |                  |     combined    |                 |
|             |                  |     with wider  |                 |
|             |                  |                 |                 |
|             |                  |    availability |                 |
|             |                  |     of tools to |                 |
|             |                  |     improve     |                 |
|             |                  |     overall     |                 |
|             |                  |     quality and |                 |
|             |                  |     allow for   |                 |
|             |                  |     increased   |                 |
|             |                  |                 |                 |
|             |                  |   reimbursement |                 |
|             |                  |     drivers     |                 |
|             |                  |     based on    |                 |
|             |                  |     quality     |                 |
+-------------+------------------+-----------------+-----------------+
| **Defining  |                  |                 |                 |
| Char        |                  |                 |                 |
| acteristics |                  |                 |                 |
| or          |                  |                 |                 |
| Attributes  |                  |                 |                 |
| of the      |                  |                 |                 |
| National    |                  |                 |                 |
| Quality     |                  |                 |                 |
| Infra       |                  |                 |                 |
| structure** |                  |                 |                 |
+-------------+------------------+-----------------+-----------------+
| **Metrics** | -   Developed by | -   Vendors     | -   Process     |
|             |     multiple     |     collaborate |     exists for  |
|             |                  |     with NQF    |     developed   |
|             |    organizations |     and quality |     and         |
|             |     with         |     measurement |     diffusion   |
|             |     differing    |                 |     of          |
|             |                  |   organizations |                 |
|             |    perspectives, |     to          |    standardized |
|             |     experience,  |     encourage   |     computable  |
|             |     objectives   |     development |     guidelines  |
|             |                  |     and         |                 |
|             | -   Limited      |                 | -               |
|             |                  |  implementation |  Identification |
|             |  standardization |     of common   |     of evidence |
|             |     of targets   |     conventions |     and best    |
|             |                  |     and         |     practices   |
|             | -   Limited      |     guidelines  |     leads to    |
|             |                  |     for measure |     practice    |
|             |  standardization |                 |     guidelines, |
|             |     of           |    development. |     which leads |
|             |     definitions  |                 |     to software |
|             |     for          | -   Measure     |     development |
|             |     numerators   |     developers  |     to capture  |
|             |     and          |     collaborate |     correct     |
|             |     denominators |     to          |     data,       |
|             |                  |     facilitate  |     calculate   |
|             | -   Operational  |     measure     |     metrics,    |
|             |     and IT       |                 |     and provide |
|             |     challenges   |  harmonization. |     CDS         |
|             |     of metrics   |                 |                 |
|             |     create       | -   Measure     | -   Feedback is |
|             |     tension with |     developers  |     provided to |
|             |     need to      |     develop     |     guideline   |
|             |     drive        |     detailed    |     developers  |
|             |     measurement  |     micro       |     and         |
|             |     forward      | -specifications |     clinical    |
|             |                  |     for         |     researchers |
|             |                  |     measures    |                 |
|             |                  |     that        |                 |
|             |                  |     facilitate  |                 |
|             |                  |                 |                 |
|             |                  |   incorporation |                 |
|             |                  |     into EHRs.  |                 |
|             |                  |                 |                 |
|             |                  | -   Standards   |                 |
|             |                  |     for data    |                 |
|             |                  |     elements    |                 |
|             |                  |     driving     |                 |
|             |                  |     quality     |                 |
|             |                  |     measurement |                 |
|             |                  |     facilitate  |                 |
|             |                  |     equivalent, |                 |
|             |                  |     consistent  |                 |
|             |                  |     reporting   |                 |
|             |                  |     from        |                 |
|             |                  |     disparate   |                 |
|             |                  |     systems     |                 |
+-------------+------------------+-----------------+-----------------+
| **EHR       | -   Recent       | -   Adoption is | -   Approaching |
| Adoption**  |     surveys      |     aided by    |     universal   |
|             |     suggest that |     reduced     |     adoption of |
|             |     adoption     |     uncertainty |     EHRs        |
|             |     rates in     |     of          |                 |
|             |     ambulatory   |     purchasers  | -               |
|             |     settings     |     because of  |                 |
|             |     range        |     product     |                 |
|             |     between 15   |                 |                 |
|             |     and 18       |   certification |                 |
|             |     percent[^1]  |                 |                 |
|             |                  | -   Adoption    |                 |
|             | -   In 2005, 10  |     increases   |                 |
|             |     percent of   |     due to      |                 |
|             |     hospitals    |     external    |                 |
|             |     had          |     reporting   |                 |
|             |     implemented  |     of          |                 |
|             |     all          |     structural  |                 |
|             |     functions of |     measures    |                 |
|             |     an EHR; 36   |     and         |                 |
|             |     percent were |     financial   |                 |
|             |     just getting |     incentives  |                 |
|             |     started; 27  |     calling for |                 |
|             |     percent had  |     certified   |                 |
|             |     low          |     products    |                 |
|             |     usability;   |                 |                 |
|             |     27 percent   | -   Increasing  |                 |
|             |     had moderate |     adoption of |                 |
|             |     usability    |     PHRs and    |                 |
|             |     (usability   |     i           |                 |
|             |     defined as   | nteroperability |                 |
|             |     the number   |     between     |                 |
|             |     of functions |     EHRs and    |                 |
|             |     and the      |     PHRs allows |                 |
|             |     percentage   |     better      |                 |
|             |     of which the |     assessments |                 |
|             |     hospital had |     based on    |                 |
|             |     fully        |     more        |                 |
|             |                  |     complete    |                 |
|             | implemented)[^2] |     data, and   |                 |
|             |                  |     therefore   |                 |
|             |                  |     better care |                 |
|             |                  |     for         |                 |
|             |                  |     patients    |                 |
+-------------+------------------+-----------------+-----------------+
| **EHR       | -   Capabilities | -   Increasing  | -   Effective   |
| Products**  |     of EHR       |                 |     EHRs        |
|             |     products     |    availability |     combined    |
|             |     lags behind  |     of EHR      |     with change |
|             |     needs for    |                 |     management  |
|             |     external     |    capabilities |     build local |
|             |     performance  |     for data    |     and         |
|             |     reporting    |     capture,    |     national    |
|             |     and quality  |                 |     capacity to |
|             |     improvement  |    measurement, |     work toward |
|             |                  |     and         |     the         |
|             | ```{=html}       |     reporting   |     nation's    |
|             | <!-- -->         |     due to      |     quality     |
|             | ```              |     product     |     improvement |
|             | -   In inpatient |                 |     priorities  |
|             |     EHRs, CDS    |   certification |                 |
|             |     consists     |     and market  | -   EHRs        |
|             |     mostly of    |     pressures   |     contain     |
|             |     alerts and   |                 |     effective   |
|             |     order sets   | -   A common    |     CDS tools   |
|             |     as part of   |     performance |     to address  |
|             |     computerized |     measurement |     full range  |
|             |     physician    |                 |     of quality  |
|             |     order entry  |  infrastructure |     improvement |
|             |     systems.     |     is in       |     goals:      |
|             |                  |     applied     |     health      |
|             | -   In           |     research    |                 |
|             |     ambulatory   |     stage that  |    maintenance, |
|             |     EHRs, CDS    |     includes    |     chronic     |
|             |     limited to   |                 |     disease     |
|             |     some         |    standardized |     management, |
|             |     medication   |     data sets,  |     patient     |
|             |     checking and |     and the     |     safety, and |
|             |     age- and     |     wide-spread |     eff         |
|             |     sex-based    |     use of HIT  | ectiveness/cost |
|             |     wellness     |     including   |     of care     |
|             |     prompting;   |     EHR         |                 |
|             |     limited      |     platforms   | -   Aggregate   |
|             |     support to   |     and         |     user        |
|             |     disease      |     i           |     experience  |
|             |     management   | nteroperability |     with CDS is |
|             |                  |     throughout  |     continually |
|             | -   CDS is       |     the         |     documented  |
|             |     difficult to |     systems.    |     and shared, |
|             |     implement    |     This        |                 |
|             |     without      |     unified     |    facilitating |
|             |     disrupting   |     platform is |     continuous  |
|             |     clinician    |     able to     |     improvement |
|             |     workflow     |     monitor and |                 |
|             |                  |     improve     | -   CDS and     |
|             | -   CDS is not   |     quality     |     related     |
|             |     explicitly   |     performance |     process     |
|             |     synchronized |                 |                 |
|             |     with quality | -               |    improvements |
|             |     measurement. | Standardization |     are         |
|             |     Utilization  |     of CDS      |     supported   |
|             |     and benefits |                 |     by          |
|             |     are          |   methodologies |                 |
|             |     inconsistent |     is          |   reimbursement |
|             |     at different |     completed,  |     structure   |
|             |     sites        |     through     |     and         |
|             |                  |                 |                 |
|             | -                |   harmonization |   certification |
|             |  Knowledge/tools |     of US and   |                 |
|             |     are not      |                 |                 |
|             |                  |   international |                 |
|             |    interoperable |     Standard    |                 |
|             |     (each vendor |     Development |                 |
|             |     /provider    |                 |                 |
|             |     recreates    |  Organizations. |                 |
|             |     the wheel)   |     Such        |                 |
|             |     and adoption |                 |                 |
|             |     is           | standardization |                 |
|             |     l            |     has allowed |                 |
|             | imited/difficult |     clinical    |                 |
|             |                  |     system      |                 |
|             | -   Guideline    |     vendors and |                 |
|             |     and measure  |     guideline   |                 |
|             |     developers   |     and         |                 |
|             |     just         |     measurement |                 |
|             |     beginning to |     development |                 |
|             |     work with    |                 |                 |
|             |     electronic   |   organizations |                 |
|             |     health       |     to perform  |                 |
|             |     record       |     applied     |                 |
|             |     vendors      |                 |                 |
|             |                  |   collaborative |                 |
|             |                  |     research    |                 |
|             |                  |     into best   |                 |
|             |                  |     practice    |                 |
|             |                  |                 |                 |
|             |                  | -   Consensus   |                 |
|             |                  |     measures    |                 |
|             |                  |     permit EHR  |                 |
|             |                  |     vendors and |                 |
|             |                  |     purchasers  |                 |
|             |                  |     to focus on |                 |
|             |                  |     needs and   |                 |
|             |                  |     solutions   |                 |
+-------------+------------------+-----------------+-----------------+
| **Data      | -   Iowa         | -   A body      | -   Stewardship |
| St          |     Foundation   |     governed by |     is          |
| ewardship** |     for Medical  |     multiple    |     consistent  |
|             |     Care (IFMC)  |                 |     across      |
|             |     hosts        |    stakeholders |                 |
|             |     hospital     |     sets        |    aggregators, |
|             |     quality data |     uniform     |     with some   |
|             |     warehouse on |     operating   |     variation   |
|             |     behalf of    |     rules and   |     where       |
|             |     CMS, which   |     standards   |     necessary   |
|             |     is used for  |     for sharing |     to be       |
|             |     physician    |     and         |     sensitive   |
|             |     and hospital |     aggregating |     to regional |
|             |     reporting    |     public and  |     priorities, |
|             |                  |     private     |     and some    |
|             | -   No consensus |     sector data |     variation   |
|             |     regarding    |     on quality  |     over time   |
|             |     utility of   |     and         |     as the      |
|             |     centralized  |     efficiency; |     national    |
|             |     'vs'         |     offers      |     agenda for  |
|             |                  |     guidance on |     improving   |
|             |    decentralized |                 |     quality     |
|             |     strategies   |  implementation |     evolves     |
|             |     for          |     of such     |                 |
|             |     aggregating  |     national    | -   Technical   |
|             |     data for     |     operating   |     assistance  |
|             |     quality      |     rules and   |     is          |
|             |     assessment.  |     standards;  |     available   |
|             |     Multiple     |     and         |     for data    |
|             |     stakeholders |     provides a  |     aggregators |
|             |     hold         |     framework   |                 |
|             |     relevant     |     for         | -   Data        |
|             |     data with    |     collecting, |     steward     |
|             |     limited      |     aggregating |     body        |
|             |     access to    |     and         |     reconciles  |
|             |     others'      |     analyzing   |     and         |
|             |                  |     data        |     enhances    |
|             |                  |     including   |     operating   |
|             |                  |     removing    |     rules and   |
|             |                  |                 |     standards   |
|             |                  | inconsistencies |     based on    |
|             |                  |                 |     learning's  |
|             |                  | -               |     from AQA    |
|             |                  |   International |     pilots and  |
|             |                  |     standards   |     emerging    |
|             |                  |     are         |     data        |
|             |                  |     harmonized  |     exchanges   |
|             |                  |     where       |                 |
|             |                  |     appropriate |                 |
|             |                  |     to          |                 |
|             |                  |     encourage   |                 |
|             |                  |     adoption    |                 |
|             |                  |     and         |                 |
|             |                  |                 |                 |
|             |                  |  implementation |                 |
|             |                  |                 |                 |
|             |                  | -   A           |                 |
|             |                  |                 |                 |
|             |                  |   collaborative |                 |
|             |                  |     of measure  |                 |
|             |                  |     developers, |                 |
|             |                  |     clinical    |                 |
|             |                  |     system      |                 |
|             |                  |     vendor,     |                 |
|             |                  |     provider    |                 |
|             |                  |     and         |                 |
|             |                  |                 |                 |
|             |                  |   practitioners |                 |
|             |                  |     begins      |                 |
|             |                  |     applied     |                 |
|             |                  |     research    |                 |
|             |                  |     and         |                 |
|             |                  |     discussion  |                 |
|             |                  |     to generate |                 |
|             |                  |     principles  |                 |
|             |                  |     for         |                 |
|             |                  |     guidance on |                 |
|             |                  |                 |                 |
|             |                  |  implementation |                 |
|             |                  |     of          |                 |
|             |                  |     operating   |                 |
|             |                  |     rules and   |                 |
|             |                  |     standards   |                 |
+-------------+------------------+-----------------+-----------------+
| **Data      | -   Clinical     | -   Data        | -   P           |
| Ag          |     data is      |     aggregation | atient-centered |
| gregation** |     aggregated   |     is enhanced |     data can be |
|             |     by providers |     by          |     aggregated  |
|             |     and payers   |     structuring |     across      |
|             |     in           |     of          |     providers   |
|             |     proprietary  |     documented  |     and payers  |
|             |     databases    |     data either |     to support  |
|             |     that are not |     through     |                 |
|             |                  |     direct      |    longitudinal |
|             |  interoperable - |     entry of    |     quality     |
|             |     -- OR into   |     structured  |     measurement |
|             |     stand-alone  |                 |     at the      |
|             |     registries   |    information, |     patient,    |
|             |     and related  |     or through  |     physician,  |
|             |     databases    |     focused and |     physician   |
|             |                  |                 |     group, plan |
|             | -   These        |    standardized |     and         |
|             |     individual   |     free text   |     hospital    |
|             |     initiatives  |     searching   |     level       |
|             |     do not       |     and parsing |                 |
|             |                  |     techniques, | -               |
|             |  comprehensively |     seamlessly  |    Longitudinal |
|             |     assess       |     to clinical |     measurement |
|             |     provider     |     users.      |     systems     |
|             |     performance  |                 |     will        |
|             |     since the    |    Standardized |     capture the |
|             |     data         |     aggregation |     performance |
|             |     collected    |     methodology |     of multiple |
|             |     are often    |     is an area  |     providers   |
|             |     insufficient |     of applied  |     caring for  |
|             |     to reliably  |     research    |     a patient;  |
|             |     measure      |     beginning   |     examine how |
|             |     quality and  |     with        |     well care   |
|             |     efficiency   |     reporting   |     is provided |
|             |     performance  |     and         |     across      |
|             |                  |     performance |     transitions |
|             |                  |     improvement |     to          |
|             |                  |                 |     different   |
|             |                  |   requirements. |     settings    |
|             |                  |     Also a      |     (e.g.,      |
|             |                  |     topic for   |     hospital to |
|             |                  |     applied     |     nursing     |
|             |                  |     research is |     home); and, |
|             |                  |     clear       |     most        |
|             |                  |                 |     important,  |
|             |                  | standardization |     evaluate    |
|             |                  |     of          |     patient     |
|             |                  |     assignment  |     outcomes    |
|             |                  |     of          |     over time.  |
|             |                  |     responsible |     The same    |
|             |                  |     care        |     data are    |
|             |                  |     providers   |     also used   |
|             |                  |     or          |     to report   |
|             |                  |                 |     to          |
|             |                  |   practitioners |     population  |
|             |                  |     in that     |     health      |
|             |                  |                 |     reporting   |
|             |                  |   collaborative |     and         |
|             |                  |     care models |                 |
|             |                  |     must allow  |    surveillance |
|             |                  |     assignment  |     (e.g., real |
|             |                  |     of          |     time        |
|             |                  |                 |     b           |
|             |                  |  accountability | iosurveillance; |
|             |                  |     to the      |     cancer      |
|             |                  |     appropriate |     registries; |
|             |                  |                 |     vital       |
|             |                  |    clinician(s) |     statistics) |
|             |                  |     or          |                 |
|             |                  |                 |                 |
|             |                  |    facility/ies |                 |
+-------------+------------------+-----------------+-----------------+
| *           | -   Providers    | -   Quality     | -   EHR's       |
| *Population |     utilize      |     reporting   |     support     |
| reporting   |     proprietary  |     modules or  |     transfer of |
| and         |     information  |     systems     |     quality     |
| feedback**  |     systems for  |     begin to    |     data to     |
|             |     performance  |     provide     |     quality     |
|             |     improvement  |     closer to   |     reporting   |
|             |     and          |     real-time   |     modules or  |
|             |     physician    |     performance |     systems     |
|             |     feedback     |     data to     |     that can    |
|             |                  |     local       |     support     |
|             |                  |                 |     automated   |
|             |                  |    organization |     and         |
|             |                  |     managers or |                 |
|             |                  |     individual  |    standardized |
|             |                  |                 |     quality     |
|             |                  |   practitioners |     reporting   |
|             |                  |     to allow    |                 |
|             |                  |     timely      |                 |
|             |                  |                 |                 |
|             |                  |  implementation |                 |
|             |                  |     of          |                 |
|             |                  |     performance |                 |
|             |                  |                 |                 |
|             |                  |    improvements |                 |
|             |                  |     through     |                 |
|             |                  |                 |                 |
|             |                  |    benchmarking |                 |
|             |                  |     and peer    |                 |
|             |                  |     comparison  |                 |
+-------------+------------------+-----------------+-----------------+
| **Public    | -   Public       | -   NQF or      | -   Quality     |
| Reporting** |     reporting is |     other body  |     data that   |
|             |     fractured    |     in          |     is          |
|             |     and          |     partnership |     pertinent,  |
|             |     inconsistent |     with        |     valid,      |
|             |     with         |     measure     |     reliable    |
|             |     multiple     |     developers  |     and         |
|             |     measures and |     defines     |                 |
|             |     data display |     consensus   |  understandable |
|             |     approaches   |     set of      |     is          |
|             |                  |     measurement |     available   |
|             | -   The public   |     priorities  |     for         |
|             |     infrequently |     to support  |     consumers   |
|             |     uses         |     public      |     to enable   |
|             |     reported     |     reporting   |     informed    |
|             |     data to      |                 |     choices     |
|             |     support      | -   Research is |     across the  |
|             |     choice of    |     done to     |     care        |
|             |     providers    |     understand  |     continuum   |
|             |                  |     consumer    |     (hospitals, |
|             |                  |     preferences |     physicians, |
|             |                  |     around data |     SNF, etc)   |
|             |                  |     display     |                 |
|             |                  |                 | -   Public      |
|             |                  | -   Achieve     |     disclosure  |
|             |                  |     agreement   |     of          |
|             |                  |     on design   |     performance |
|             |                  |     of results  |     data,       |
|             |                  |     retrieval   |     payment     |
|             |                  |     function    |     policies,   |
|             |                  |     and on      |     and         |
|             |                  |     levels of   |     performance |
|             |                  |     data to be  |     improvement |
|             |                  |     available   |     processes   |
|             |                  |     for use     |     to          |
|             |                  |     purposes -- |     providers   |
|             |                  |     Access to   |     (both       |
|             |                  |     Results     |     clinicians  |
|             |                  |                 |     and         |
|             |                  | -   Design      |                 |
|             |                  |     results     |  institutions), |
|             |                  |     retrieval   |     purchasers, |
|             |                  |     source for  |     and         |
|             |                  |     flexibility |                 |
|             |                  |     in an       |  beneficiaries, |
|             |                  |     evolving    |     to promote  |
|             |                  |     measurement |                 |
|             |                  |     industry    |  accountability |
|             |                  |                 |     among       |
|             |                  |                 |     providers   |
|             |                  |                 |     and aid     |
|             |                  |                 |     consumers   |
|             |                  |                 |     in making   |
|             |                  |                 |     informed    |
|             |                  |                 |     choices.    |
|             |                  |                 |                 |
|             |                  |                 | -   Measurement |
|             |                  |                 |     data is     |
|             |                  |                 |                 |
|             |                  |                 |    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     |
+-------------+------------------+-----------------+-----------------+
| Int         | -   More than    | -   Policies,   | -   Policies,   |
| ermediaries |     100 RHIOs    |     appropriate |     appropriate |
| (RHIOs,     |     are in       |     oversight   |     oversight,  |
| QPICS)      |     development  |     and         |     and a       |
|             |     across the   |     sustainable |     sustainable |
|             |     US but they  |     business    |     business    |
|             |     are not yet  |     models are  |     model are   |
|             |                  |     established |     in place    |
|             |   interoperable. |     for health  |     for health  |
|             |     Only one is  |     information |     information |
|             |     exchanging   |     exchange at |     exchange at |
|             |     clinical     |     regional,   |     regional,   |
|             |     data and     |     state and   |     state and   |
|             |     merging it   |     national    |     national    |
|             |     with claims  |     levels that |     levels that |
|             |     data for the |     protect     |     both        |
|             |     purposes of  |     privacy and |     protects    |
|             |     quality      |     security    |     privacy and |
|             |     measurement  |     and enables |     security    |
|             |     and          |     appropriate |     and enables |
|             |     reporting    |     secondary   |     appropriate |
|             |                  |     uses of     |     secondary   |
|             | -   Quality and  |     clinical    |     uses of     |
|             |     pricing      |     data for    |     clinical    |
|             |     information  |     quality     |     data for    |
|             |                  |     management  |     quality     |
|             |   collaboratives |                 |     management  |
|             |     (starting    |                 |                 |
|             |     with AQA     |                 |                 |
|             |     Pilots) are  |                 |                 |
|             |     informing    |                 |                 |
|             |     ways to      |                 |                 |
|             |     capture,     |                 |                 |
|             |     aggregate,   |                 |                 |
|             |     analyze and  |                 |                 |
|             |     report       |                 |                 |
|             |     quality data |                 |                 |
|             |     in six       |                 |                 |
|             |     different    |                 |                 |
|             |     regions,     |                 |                 |
|             |     most         |                 |                 |
|             |     dependent on |                 |                 |
|             |     claims data  |                 |                 |
+-------------+------------------+-----------------+-----------------+
| Privacy and | -   The Health   |                 | -   A national  |
| Security    |     Insurance    |                 |     framework   |
| policies,   |     Portability  |                 |     for the     |
| including   |     and          |                 |     secondary   |
| secondary   |                  |                 |     use of      |
| uses of     |   Accountability |                 |     health data |
| data        |     Act of 1996  |                 |     that        |
|             |     (HIPAA)      |                 |     includes a  |
|             |     applies to   |                 |     robust      |
|             |     health       |                 |                 |
|             |     information  |                 |  infrastructure |
|             |     created or   |                 |     of          |
|             |     maintained   |                 |     policies,   |
|             |     by health    |                 |     standards,  |
|             |     plans,       |                 |     and best    |
|             |     health care  |                 |     practices   |
|             |                  |                 |     facilitates |
|             |  clearinghouses, |                 |     the broad   |
|             |     and health   |                 |     and         |
|             |     care         |                 |     multiple    |
|             |     providers    |                 |     purpose     |
|             |     who engage   |                 |     repeated    |
|             |     in certain   |                 |     collection, |
|             |     electronic   |                 |     storage,    |
|             |                  |                 |                 |
|             |    transactions, |                 |    aggregation, |
|             |     but there is |                 |     linkage,    |
|             |     a potential  |                 |     and         |
|             |     lack of      |                 |                 |
|             |     protection   |                 |    transmission |
|             |     of personal  |                 |     of health   |
|             |     health       |                 |     data with   |
|             |     information  |                 |     appropriate |
|             |     (PHI) when   |                 |     protections |
|             |     used by      |                 |     for         |
|             |     entities not |                 |     legitimate  |
|             |     explicitly   |                 |     secondary   |
|             |     covered by   |                 |     use. Rules  |
|             |     HIPAA        |                 |     and         |
|             |     legislation  |                 |     guidelines  |
|             |     or           |                 |     will have   |
|             |     regulations. |                 |     been put in |
|             |     In fact,     |                 |     place early |
|             |     there may be |                 |     on in the   |
|             |     mistaken     |                 |     process in  |
|             |     perceptions  |                 |     order to    |
|             |     that HIPAA   |                 |     enable      |
|             |     assures      |                 |     quality     |
|             |     protection   |                 |     programs to |
|             |     of all       |                 |     continue    |
|             |     secondary    |                 |                 |
|             |     use of PHI   |                 |   uninterrupted |
|             |     by users,    |                 |     by          |
|             |     beyond those |                 |     secondary   |
|             |     uses and     |                 |     data issues |
|             |     users        |                 |     or          |
|             |     (covered     |                 |     challenges  |
|             |     entities)    |                 |                 |
|             |     specifically |                 | -   Appropriate |
|             |     noted in     |                 |                 |
|             |     HIPAA        |                 | confidentiality |
|             |                  |                 |     protections |
|             |                  |                 |     are in      |
|             |                  |                 |     place for   |
|             |                  |                 |     the         |
|             |                  |                 |     submission  |
|             |                  |                 |     of patient  |
|             |                  |                 |     data that   |
|             |                  |                 |     are in      |
|             |                  |                 |     strict      |
|             |                  |                 |     compliance  |
|             |                  |                 |     with the    |
|             |                  |                 |     regulations |
|             |                  |                 |     of the      |
|             |                  |                 |     Health      |
|             |                  |                 |     Insurance   |
|             |                  |                 |     Portability |
|             |                  |                 |     and         |
|             |                  |                 |                 |
|             |                  |                 |  Accountability |
|             |                  |                 |     Act.        |
|             |                  |                 |     Potential   |
|             |                  |                 |     problems of |
|             |                  |                 |     patients    |
|             |                  |                 |     opting out  |
|             |                  |                 |     of having   |
|             |                  |                 |     their data  |
|             |                  |                 |     included in |
|             |                  |                 |     a data      |
|             |                  |                 |     repository  |
|             |                  |                 |     are         |
|             |                  |                 |     addressed   |
|             |                  |                 |     and impacts |
|             |                  |                 |     on          |
|             |                  |                 |     accurately  |
|             |                  |                 |     assessing   |
|             |                  |                 |     the quality |
|             |                  |                 |     of care on  |
|             |                  |                 |     both the    |
|             |                  |                 |     national    |
|             |                  |                 |     and         |
|             |                  |                 |     community   |
|             |                  |                 |     levels are  |
|             |                  |                 |     understood  |
+-------------+------------------+-----------------+-----------------+
| **Enablers  |                  |                 |                 |
| and         |                  |                 |                 |
| Barriers**  |                  |                 |                 |
+-------------+------------------+-----------------+-----------------+
|             | [Enabl           | [Enable         | [Enable         |
|             | ers]{.underline} | rs]{.underline} | rs]{.underline} |
|             |                  |                 |                 |
|             | -   Quality      | -               | -   Expansion   |
|             |     alliances -- |   Certification |     of sharing  |
|             |                  |     based on    |     of          |
|             |    collaboration |     criteria to |     electronic  |
|             |     between      |     enable      |     pharmacy    |
|             |     providers,   |     reporting   |     data        |
|             |     purchasers,  |     of an       |     between     |
|             |     consumers    |     expanded    |     pharmacy    |
|             |     and          |     set of AQA  |     benefit     |
|             |     accreditors  |     and HQA     |     managers    |
|             |     -- are       |     quality     |     and         |
|             |     producing    |     measurement |     clinicians  |
|             |     uniform      |     in EHRs     |     nationwide  |
|             |     standards    |                 |                 |
|             |     for sharing  | -   Improvement | -               |
|             |     and          |     of health   |   Certification |
|             |     aggregating  |     IT          |     of clinical |
|             |     health data  |                 |     decision    |
|             |     and for      |  infrastructure |     support     |
|             |     public       |     and ability |                 |
|             |     reporting    |     to share    |    capabilities |
|             |     for          |     electronic  |     in EHRs     |
|             |     hospitals    |     health      |                 |
|             |     and          |     data; e.g., | [Barrie         |
|             |     physicians   |     new         | rs]{.underline} |
|             |                  |                 |                 |
|             | -                |   e-prescribing |                 |
|             |    Collaboration |     standards   |                 |
|             |     between      |     will        |                 |
|             |     regional     |     encourage   |                 |
|             |     quality      |     sharing of  |                 |
|             |     measurement  |     pharmacy    |                 |
|             |     initiatives  |     data        |                 |
|             |     and RHIOs or |     between     |                 |
|             |     NHIN service |     pharmacy    |                 |
|             |     providers    |     benefit     |                 |
|             |                  |     managers    |                 |
|             | -   Development  |     and         |                 |
|             |     of viable    |     clinicians  |                 |
|             |     business     |     in some     |                 |
|             |     models for   |     regions     |                 |
|             |     regional     |                 |                 |
|             |     health       | -   Sharing of  |                 |
|             |     information  |     data with   |                 |
|             |     exchange     |     patients'   |                 |
|             |     networks     |     PHRs will   |                 |
|             |     that support |     increase    |                 |
|             |     provider     |     consumer    |                 |
|             |     EHRs, data   |     stake in    |                 |
|             |     aggregators  |     quality     |                 |
|             |     and public   |     measurement |                 |
|             |     reporting    |                 |                 |
|             |     entities     | -   Pay-        |                 |
|             |                  | for-performance |                 |
|             | -   Quality use  |     and payment |                 |
|             |     case guiding |     reform to   |                 |
|             |     NHIN         |     encourage   |                 |
|             |     contracts in |     quality     |                 |
|             |     2007         |     measurement |                 |
|             |                  |     and         |                 |
|             | -   Quality use  |     reporting   |                 |
|             |     case guiding |                 |                 |
|             |     standards    | -   Education   |                 |
|             |                  |     of          |                 |
|             |    harmonization |     consumers   |                 |
|             |     and          |     on how to   |                 |
|             |     inpatient    |     obtain data |                 |
|             |     and          |     and assess  |                 |
|             |     ambulatory   |     quality of  |                 |
|             |     EHR          |     care so     |                 |
|             |                  |     that they   |                 |
|             |    certification |     can take    |                 |
|             |     criteria in  |     ownership   |                 |
|             |     2007         |     of their    |                 |
|             |                  |     health      |                 |
|             | -   Measures     |     information |                 |
|             |     that span    |                 |                 |
|             |     care         | -               |                 |
|             |     delivery     |  Identification |                 |
|             |                  |     of ways to  |                 |
|             | -   Quickly      |     reduce      |                 |
|             |     accessible   |     costs       |                 |
|             |     ambulatory   |     through     |                 |
|             |     records      |     quality     |                 |
|             |     would ensure |     measurement |                 |
|             |     compliance   |     and         |                 |
|             |     with         |     reporting   |                 |
|             |     time-based   |                 |                 |
|             |     standards of | -   Entity that |                 |
|             |     care and     |     reviews     |                 |
|             |     help find    |     clinical    |                 |
|             |     co           |     evidence    |                 |
|             | ntraindications. |     and         |                 |
|             |                  |     collates it |                 |
|             | -   Standard     |     for use in  |                 |
|             |     approach for |     development |                 |
|             |     EHRs to      |     of practice |                 |
|             |     routinely    |     guidelines  |                 |
|             |     produce      |                 |                 |
|             |     quality data | -   Cultural    |                 |
|             |     based on     |     change that |                 |
|             |     approved     |     encourages  |                 |
|             |     measures     |     performance |                 |
|             |                  |     reporting   |                 |
|             | -   The          |     and         |                 |
|             |     designation  |     improved    |                 |
|             |     of a         |     quality of  |                 |
|             |     national     |     care        |                 |
|             |     health data  |                 |                 |
|             |     stewardship  | -   Software    |                 |
|             |     entity       |     systems     |                 |
|             |     (separate    |     help with   |                 |
|             |     from a       |     data entry  |                 |
|             |     priority-set |     and         |                 |
|             | ting/rule-making |     clinical    |                 |
|             |     entity) to   |                 |                 |
|             |     oversee      |   documentation |                 |
|             |     appropriate  |     input to    |                 |
|             |     use of data  |     minimize    |                 |
|             |                  |     human and   |                 |
|             | -   Data         |     system      |                 |
|             |     aggregation  |     error       |                 |
|             |     and data     |                 |                 |
|             |     stewardship  | [Barrie         |                 |
|             |     supported by | rs]{.underline} |                 |
|             |     contract law |                 |                 |
|             |     (however,    | -   Integration |                 |
|             |     new          |     of new      |                 |
|             |     legislation  |     technology  |                 |
|             |     is unlikely) |                 |                 |
|             |                  |                 |                 |
|             | -   Additional   |                 |                 |
|             |     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   |                 |                 |
|             |                  |                 |                 |
|             | -   Availability |                 |                 |
|             |     of a         |                 |                 |
|             |     knowledge    |                 |                 |
|             |     management   |                 |                 |
|             |     repository   |                 |                 |
|             |     in the       |                 |                 |
|             |     public       |                 |                 |
|             |     domain       |                 |                 |
|             |                  |                 |                 |
|             | -   A complete   |                 |                 |
|             |     medical      |                 |                 |
|             |     record       |                 |                 |
|             |     across       |                 |                 |
|             |     points of    |                 |                 |
|             |     care         |                 |                 |
|             |     obtained via |                 |                 |
|             |     health       |                 |                 |
|             |     information  |                 |                 |
|             |     exchange     |                 |                 |
|             |     networks to  |                 |                 |
|             |     enable       |                 |                 |
|             |     intelligent  |                 |                 |
|             |     alerts to    |                 |                 |
|             |     providers    |                 |                 |
|             |                  |                 |                 |
|             | -   Scalable     |                 |                 |
|             |     open source  |                 |                 |
|             |     software     |                 |                 |
|             |     development  |                 |                 |
|             |     to reduce    |                 |                 |
|             |     costs of     |                 |                 |
|             |     multiple     |                 |                 |
|             |     approaches   |                 |                 |
|             |     to data      |                 |                 |
|             |     aggregation  |                 |                 |
|             |                  |                 |                 |
|             | [Barri           |                 |                 |
|             | ers]{.underline} |                 |                 |
|             |                  |                 |                 |
|             | -   Limited set  |                 |                 |
|             |     of national  |                 |                 |
|             |     consensus    |                 |                 |
|             |     measures;    |                 |                 |
|             |     robust       |                 |                 |
|             |     measures not |                 |                 |
|             |     yet          |                 |                 |
|             |     developed    |                 |                 |
|             |     for all      |                 |                 |
|             |     physician    |                 |                 |
|             |     specialties  |                 |                 |
|             |                  |                 |                 |
|             | -   Lack of      |                 |                 |
|             |     standards    |                 |                 |
|             |     for data     |                 |                 |
|             |     definition   |                 |                 |
|             |     and          |                 |                 |
|             |     aggregation  |                 |                 |
|             |                  |                 |                 |
|             | -   Limited      |                 |                 |
|             |     focus of     |                 |                 |
|             |     current      |                 |                 |
|             |     measurement  |                 |                 |
|             |                  |                 |                 |
|             | -   Lack of      |                 |                 |
|             |     standardized |                 |                 |
|             |     mechanisms   |                 |                 |
|             |     for external |                 |                 |
|             |     reporting    |                 |                 |
|             |     including    |                 |                 |
|             |     data         |                 |                 |
|             |     stewardship  |                 |                 |
|             |                  |                 |                 |
|             | -   Lack of      |                 |                 |
|             |     alignment of |                 |                 |
|             |                  |                 |                 |
|             |    reimbursement |                 |                 |
|             |     with quality |                 |                 |
|             |     performance  |                 |                 |
|             |                  |                 |                 |
|             | -   Gaps in      |                 |                 |
|             |     regulations  |                 |                 |
|             |     and          |                 |                 |
|             |     practices    |                 |                 |
|             |     relating to  |                 |                 |
|             |                  |                 |                 |
|             | privacy/security |                 |                 |
|             |     and          |                 |                 |
|             |     secondary    |                 |                 |
|             |     use of data  |                 |                 |
|             |                  |                 |                 |
|             | -   Translation  |                 |                 |
|             |     of research  |                 |                 |
|             |     into         |                 |                 |
|             |     practice at  |                 |                 |
|             |     the point of |                 |                 |
|             |     care         |                 |                 |
|             |                  |                 |                 |
|             | -   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 |                 |                 |
|             |                  |                 |                 |
|             | -   Current      |                 |                 |
|             |     programs     |                 |                 |
|             |     have         |                 |                 |
|             |     differing    |                 |                 |
|             |     requirements |                 |                 |
|             |     and lack the |                 |                 |
|             |     coordination |                 |                 |
|             |     needed for a |                 |                 |
|             |     systematic   |                 |                 |
|             |     approach     |                 |                 |
|             |     toward       |                 |                 |
|             |     achieving    |                 |                 |
|             |     sound        |                 |                 |
|             |     quality      |                 |                 |
|             |     measurement  |                 |                 |
|             |                  |                 |                 |
|             | -   Gaps in      |                 |                 |
|             |     quality      |                 |                 |
|             |     management   |                 |                 |
|             |     capabilities |                 |                 |
|             |     of EHRs;     |                 |                 |
|             |     Current      |                 |                 |
|             |     electronic   |                 |                 |
|             |     health       |                 |                 |
|             |     records do   |                 |                 |
|             |     not support  |                 |                 |
|             |     efficient    |                 |                 |
|             |     data capture |                 |                 |
|             |                  |                 |                 |
|             | -   Clinical     |                 |                 |
|             |                  |                 |                 |
|             |    documentation |                 |                 |
|             |     is often     |                 |                 |
|             |     unstructured |                 |                 |
|             |     and uses     |                 |                 |
|             |                  |                 |                 |
|             | non-standardized |                 |                 |
|             |     nomenclature |                 |                 |
|             |                  |                 |                 |
|             | -   Clinical     |                 |                 |
|             |                  |                 |                 |
|             |    documentation |                 |                 |
|             |     is sometimes |                 |                 |
|             |     not          |                 |                 |
|             |     encouraged   |                 |                 |
|             |     and is often |                 |                 |
|             |     the last     |                 |                 |
|             |     module       |                 |                 |
|             |     implemented  |                 |                 |
|             |     by           |                 |                 |
|             |     hospitals,   |                 |                 |
|             |     as it        |                 |                 |
|             |     requires     |                 |                 |
|             |     significant  |                 |                 |
|             |     change       |                 |                 |
|             |     management   |                 |                 |
|             |     for          |                 |                 |
|             |     clinicians   |                 |                 |
|             |                  |                 |                 |
|             | -   Consumers    |                 |                 |
|             |     need to have |                 |                 |
|             |     information  |                 |                 |
|             |     on why       |                 |                 |
|             |     patient is   |                 |                 |
|             |     moving to a  |                 |                 |
|             |     new setting. |                 |                 |
|             |     Payment      |                 |                 |
|             |     needs to     |                 |                 |
|             |     reflect the  |                 |                 |
|             |     push to      |                 |                 |
|             |     coordination |                 |                 |
|             |     (align       |                 |                 |
|             |     incentives   |                 |                 |
|             |     with         |                 |                 |
|             |                  |                 |                 |
|             |    coordination) |                 |                 |
|             |                  |                 |                 |
|             | -   HIE is       |                 |                 |
|             |     operational  |                 |                 |
|             |     in less than |                 |                 |
|             |     10 regions   |                 |                 |
|             |     to enable    |                 |                 |
|             |     data sharing |                 |                 |
|             |     for Quality  |                 |                 |
|             |     Reporting    |                 |                 |
|             |                  |                 |                 |
|             | -   Economic     |                 |                 |
|             |     pressures -- |                 |                 |
|             |     higher costs |                 |                 |
|             |     of doing     |                 |                 |
|             |     business,    |                 |                 |
|             |     declining    |                 |                 |
|             |                  |                 |                 |
|             |    reimbursement |                 |                 |
|             |     and the      |                 |                 |
|             |     expectation  |                 |                 |
|             |     of           |                 |                 |
|             |     implementing |                 |                 |
|             |     information  |                 |                 |
|             |     technology   |                 |                 |
|             |     solutions    |                 |                 |
|             |                  |                 |                 |
|             | -   Current      |                 |                 |
|             |     culture and  |                 |                 |
|             |     stakeholder  |                 |                 |
|             |     buy-in does  |                 |                 |
|             |     not fully    |                 |                 |
|             |     encompass    |                 |                 |
|             |     real-time    |                 |                 |
|             |     data capture |                 |                 |
|             |                  |                 |                 |
|             | -   A complete   |                 |                 |
|             |     medical      |                 |                 |
|             |     record       |                 |                 |
|             |     across       |                 |                 |
|             |     points of    |                 |                 |
|             |     care is      |                 |                 |
|             |     needed for   |                 |                 |
|             |     intelligent  |                 |                 |
|             |     alerts to    |                 |                 |
|             |     providers,   |                 |                 |
|             |     but this     |                 |                 |
|             |     coordination |                 |                 |
|             |     does not yet |                 |                 |
|             |     exist        |                 |                 |
|             |                  |                 |                 |
|             | -   Some alerts  |                 |                 |
|             |     from         |                 |                 |
|             |     clinical     |                 |                 |
|             |     decision     |                 |                 |
|             |     support      |                 |                 |
|             |     systems can  |                 |                 |
|             |     be           |                 |                 |
|             |     burdensome   |                 |                 |
|             |     or           |                 |                 |
|             |     irrelevant   |                 |                 |
+-------------+------------------+-----------------+-----------------+

[^1]: Gans D, Kralewski J, Hammons T, Dowd B. Medical groups' adoption
    of electronic health records and information systems. Health Affairs
    2005; 24(5):1323-33.

    ^?^ Burt CW, Sisk JE. Which physicians and practices are using
    electronic medical records? Health Affairs 2005; 24(5):1334-43.

[^2]: http://www.ahapolicyforum.org/ahapolicyforum/resources/content/FINALNonEmbITSurvey105.pdf