Quality Workgroup Executive Summary of the End State Vision

In response to the American Health Information Community (the Community), the Quality Workgroup prepared the following document to assist the Community in its deliberations on recommendations it will make to the Secretary. The concepts and statements in this document are directed to the Community and subject to further deliberation by the Community.

In the future, stakeholders, including consumers, purchasers, providers, policymakers, researchers, accrediting and oversight bodies, will rely on transparent reporting of quality performance and quality improvement to inform their decision making about care. Information technology and the sharing of health information across a network of regional health information entities using data from electronic health records (EHRs), personal health records (PHRs), and strong clinical decision support (CDS) systems will assist providers in ensuring that the right care is delivered to the right patient - every time. Consumers and policymakers will use these same systems to understand how well the nation as a whole and individual providers are doing in improving care and health status in accordance with national, regional, and local priorities.

Achieving this vision will radically transform the way health care information is shared among various stakeholders and, in particular, how it is used by consumers. Consumers will be empowered to take a more active role in their health care. Transformational change among stakeholder groups of today's health care system will be required to achieve this vision. A strong public-private partnership and a joint commitment to producing value for health care consumers are critical. Responsibility for improving quality and value in health care transcends any one stakeholder group, and true alignment of incentives across the health care value chain requires active participation and engagement from each link in that chain.

Defining Characteristics of the Health Care System with Respect to the Quality Enterprise
Receiving Care Managing Clinician-Patient Interactions Managing Health of Defined Populations Coordination of Care Improving Quality Measuring and Reporting Quality Reimbursement

The envisioned changes in the defining attributes and characteristics of today's health care system are described below, illustrated by their impact on key stakeholders.

Consumers: Consumers will be better educated, more empowered, and more engaged in their health care through the increased availability of personal health records and use of electronic health records by their providers. Growing awareness of provider performance information will enable informed decision making about their choice of providers. Access and utilization of cost and quality information along with education in how to interpret both will strengthen their experience. The capacity to gather evidence as a by-product of clinical interactions will enhance the availability of evidence-based information on treatment options, permitting customization of care to individual needs and preferences.

Providers: Providers will have access to performance information, coordinated guidelines and protocols. Market differentiation will occur based on safety, quality and cost performance. Linking information networks will enhance care coordination and allow easy communication between providers. Utilizing EHR's at the point of decision making along with other interventions, like clinical decision support tools, will help address a wide range of condition-specific guidelines and patient safety. Providers will receive incentives to continually improve through payment as well as non financial recognition such as maintenance of professional certification and Continuing Medical Education (CME).

Payers: The adoption of national consensus metrics and unified data stewardship will significantly reduce the administrative and economic burden of physician performance measurement. More of healthcare spending will be performance-based, due to better reliability of metrics and widespread adoption of health information technology and evidence to improve quality. Benefit design, provider relations and consumer strategies will all promote transparency and value.

Employers: National consensus quality goals and standards for quality performance reporting will provide a comprehensive basis for employee awareness and incentives. The choice of health plans, physicians, and hospitals will be enhanced by the availability of performance data.

Research Community: Guideline developers and clinical researchers will collect performance measurement data and refine the evidence base and practice guidelines in near real-time. Measures will be dynamically adjusted based on refinements by guideline developers and the clinical research community.

Policymakers: Health care policy will be unified around the national quality agenda and will incorporate gaps identified in the National Healthcare Quality and Disparities Report. Policy decisions will be reviewed annually based on population-based reporting and analysis of outcomes enabling modifications, enhancements or discontinuation of policies as appropriate.

Accreditors: Accreditors will incorporate a robust measurement set based on a strong evidence base. Continuous evaluation of providers will be based on informative, easily accessible data. Tools for improvement will be tailored to individual providers and care settings.

To support the envisioned changes to the health care system, there are specific obstacles that must be overcome as well as various aspects of the national quality infrastructure that must be bolstered, and, in some cases, developed de novo. These barriers and enablers are summarized in the following table:

Barriers	Enablers
Lack of a clear business model for health information exchange Lack of a clear business model for quality Limited set of national consensus measures; robust measures not yet developed for all physician specialties Lack of standards for data collection and aggregation Lack of standardized mechanisms for external reporting including data stewardship Lack of alignment of payment with quality performance Gaps in regulations and practices relating to privacy/security and secondary use of data Slow translation of research into practice at the point of care Quality assessment tightly linked with site of care or individual clinicians; few integrated or episode-based metrics Lack of coordination in quality measurement Gaps in quality management capabilities of EHRs Clinical documentation unstructured using non-standardized nomenclature HIE operational in few regions Poor provider economics- higher costs of doing business, declining reimbursement and the expectation of implementing information technology solutions Lack of a complete medical record to support CDS Clear value proposition supports the use of HIT capabilities for quality assessment, quality improvement and informed decision making	Collaboration between providers, purchasers, consumers and accreditors produce uniform standards for sharing and aggregating health data and for public reporting Collaboration between regional quality measurement initiatives and RHIOs or NHIN service providers Standard approach for EHRs to routinely produce quality data based on approved measures that span care delivery Designation of a national health data stewardship entity to oversee appropriate use of data Comprehensive medical record across points of care obtained via health information exchange networks to enable intelligent alerts to providers Measure developers identify data and HIT requirements in order to implement measures into clinical care and software Certification of HIT based on criteria to enable reporting of an expanded set of AQA and HQA quality measurement in EHRs Education of consumers on how to obtain data and assess quality of care along with sharing of data with patients' PHRs will increase consumer stake in quality measurement Overall payment system that provides incentives for quality and safe care Cultural change that encourages performance reporting Certification of clinical decision support capabilities in EHRs 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

Barriers

Enablers

Lack of a clear business model for health information exchange
Lack of a clear business model for quality
Limited set of national consensus measures; robust measures not yet developed for all physician specialties
Lack of standards for data collection and aggregation
Lack of standardized mechanisms for external reporting including data stewardship
Lack of alignment of payment with quality performance
Gaps in regulations and practices relating to privacy/security and secondary use of data
Slow translation of research into practice at the point of care
Quality assessment tightly linked with site of care or individual clinicians; few integrated or episode-based metrics
Lack of coordination in quality measurement
Gaps in quality management capabilities of EHRs
Clinical documentation unstructured using non-standardized nomenclature
HIE operational in few regions
Poor provider economics- higher costs of doing business, declining reimbursement and the expectation of implementing information technology solutions
Lack of a complete medical record to support CDS
Clear value proposition supports the use of HIT capabilities for quality assessment, quality improvement and informed decision making

Collaboration between providers, purchasers, consumers and accreditors produce uniform standards for sharing and aggregating health data and for public reporting
Collaboration between regional quality measurement initiatives and RHIOs or NHIN service providers
Standard approach for EHRs to routinely produce quality data based on approved measures that span care delivery
Designation of a national health data stewardship entity to oversee appropriate use of data
Comprehensive medical record across points of care obtained via health information exchange networks to enable intelligent alerts to providers
Measure developers identify data and HIT requirements in order to implement measures into clinical care and software
Certification of HIT based on criteria to enable reporting of an expanded set of AQA and HQA quality measurement in EHRs
Education of consumers on how to obtain data and assess quality of care along with sharing of data with patients' PHRs will increase consumer stake in quality measurement
Overall payment system that provides incentives for quality and safe care
Cultural change that encourages performance reporting
Certification of clinical decision support capabilities in EHRs
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