Reference List

  1. Agency for Healthcare Reasearch and Quality (AHRQ). Agency for Healthcare Reasearch and Quality (AHRQ)
    Notes: AHRQ is the Agency for Healthcare Research and Quality-the Nation's lead Federal agency for research on health care quality, costs, outcomes, and patient safety. The Healthcare Research and Quality Act of 1999 reauthorizes the Agency for Health Care Policy and Research (AHCPR), changing its name to the Agency for Healthcare Research and Quality (AHRQ). It also affirms the Agency's existing goals and research priorities. On December 6, 1999, President Clinton signed the Healthcare Research and Quality Act of 1999, reauthorizing the Agency for Health Care Policy and Research (AHCPR) until the end of fiscal year 2005. The authorizing legislation establishes Federal agencies and programs and outlines their roles and responsibilities.
    Reauthorization-the process of renewing an agency's original legislation-gives Congress an opportunity to make changes to the original roles and responsibilities it outlined. AHCPR has been operating without an authorization since 1995, but it has received operating funds through the congressional appropriations process. One of the most visible changes resulting from the Act is that AHCPR will now be known as the Agency for Healthcare Research and Quality (AHRQ). The new law also changes the title of the Administrator of AHCPR to the Director of AHRQ.
    The new name is significant because it:
    · Reaffirms that AHRQ is a scientific research agency.
    · Corrects the misperception that the Agency determines Federal healthcare policies and regulations by removing "policy" from the Agency name.
    · Adds the word "quality" to the Agency's name, thus establishing AHRQ as the lead Federal agency on quality of care research, with new responsibility to coordinate all Federal quality improvement efforts and health services research. The Agency has been fulfilling this function since 1998 through its leadership role in the Federal Quality Interagency Coordination (QuIC) Task Force.
    This legislation eliminates a requirement that the Agency support the development of clinical practice guidelines. The Agency ended its clinical guidelines program in 1996.
    The Agency now supports the development of evidence reports through its 12 Evidence-based Practice Centers and the dissemination of evidence-based guidelines through the Agency's National Guideline Clearinghouse™.

  2. Centers for Medicare & Medicaid Services (CMS). Physician Focused Quality Initiative (PFQI)
    Notes: The Physician Focused Quality Initiative builds upon ongoing CMS strategies and programs in other health care settings in order to: (1) assess the quality of care for key illnesses and clinical conditions that affect many people with Medicare, (2) support clinicians in providing appropriate treatment of the conditions identified, (3) prevent health problems that are avoidable, and (4) investigate the concept of payment for performance.
    The Physician Focused Quality Initiative includes the Doctor's Office Quality (DOQ) Project, the Doctor's Office Quality Information Technology (DOQ-IT) Project, Vista-Office EHR and several Demonstration Projects and Evaluation Reports.

  3. Centers for Medicare & Medicaid Services (CMS). Centers for Medicare & Medicaid Services (CMS) Web Site

  4. James NW. MMC - Application Downloads EHRLinks Web Site

  5. James NW. MMC - Application Downloads Web Site

  6. WorldVistA. WorldVistA Web Site

  7. Wennberg J, Gittelsohn. Small area variations in health care delivery. Science 1973; 182(117):1102-1108.
    Web Site: PM:4750608
    Notes: DA - 19740111
    IS - 0036-8075
    LA - eng
    PT - Journal Article
    SB - IM

  8. Baker, G and Carter, B. Provider Pay-for-Performance Incentive Programs: 2004 National Study Results. <[11] Journal> 1-5-1989; <[12] Volume>.
    Web Site:

  9. Berwick DM. Continuous improvement as an ideal in health care. N Engl J Med 1989; 320(1):53-56.
    Web Site: PM:2909878
    Notes: DA - 19890201
    IS - 0028-4793
    LA - eng
    PT - Journal Article
    SB - AIM
    SB - IM

  10. Institute of Medicine. Clinical practice guidelines: directions for a new program. <[11] Journal> 1990; <[12] Volume>.

  11. Institute of Medicine. Guidelines for clinical practice: from development to use. <[11] Journal> 1992; <[12] Volume>.

  12. Blumenthal D. The Variation Phenomenon in 1994. N Engl J Med 1994; 331(15):1017-1018.
    Web Site:

  13. Leape LL. Error in medicine. JAMA: The Journal of the American Medical Association 1994; 272(23):1851-1857.
    Web Site:

  14. Bates DW, Cullen DJ, Laird N et al. Incidence of adverse drug events and potential adverse drug events. Implications for prevention. ADE Prevention Study Group. JAMA: The Journal of the American Medical Association 1995; 274(1):29-34.
    Web Site:

  15. Leape LL, Bates DW, Cullen DJ et al. Systems analysis of adverse drug events. ADE Prevention Study Group. JAMA: The Journal of the American Medical Association 1995; 274(1):35-43.
    Web Site:

  16. Berwick DM. Quality of Health Care Part 5 of 6: Payment by Capitation and the Quality of Care. New England Journal of Medicine 1996; 335(16):1227-1231.

  17. Blumenthal D. Quality of Health Care Part 4 of 6: The Origins of the Quality-Of-Care Debate. New England Journal of Medicine 1996; 335(15):1146-1149.

  18. Blumenthal D, Epstein AM. Quality of Health Care Part 6 of 6: The Role of Physicians in the Future of Quality Management. New England Journal of Medicine 1996; 335(17):1328-1331.

  19. Blumenthal D. Quality of Health Care Part 1 of 6: Quality of Care - What Is It? New England Journal of Medicine 1996; 335(12):891-894.
    Notes: Explores definitions of quality of care.
    Contrasts recently held prespective of physician as judge and manager of quality of care with trend toward care management by patients, society, third party payers, and purchasers. Introduces new language of the quality of care debate:
    - observed and expected mortality
    - outcomes and process measures
    - SF-36 (36 item short form health survey developed by RAND for the Medical Outcomes Study (MOS))
    - case-mix
    - case-severity adjustments
    - profiles
    - HEDIS measures (The Health Plan Employer Data and Information Set (HEDIS) developed by the National Committee for Quality Assurance (NCQA))
    - control charts
    - continuous quality improvement
    - total quality management
    - crritical paths
    - appropriateness criteria

    1980: Donabedian: "that kind of care which is expected to maximize an inclusive measure of patient welfare, after one has taken account of the balance of expected gains and losses that attend the process of care in all its parts."
    1984: American Medical Association (AMA): quality of care is that "which consistently contributes to the improvement or maintenance of quality and/or duration of life."
    1990: Institute of Medicine (IOM): quality consists of the "degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge."
    Perspectives on quality: physician, patient, third-aprty payers, organized purchasers, employers, unions, consumer cooperatives.
    National Committee for Quality Assurance (NCQA) and other groups: Develop standard measures of quality.

  20. Brook RH, McGlynn EA. Quality of Health Care Part 2 of 6: Measuring Quality of Care. New England Journal of Medicine 1996; 335(13):966-969.
    Notes: Explores methods for measuring quality of care.
    Quality of care can be evaluated on the basis of:
    - Structure - characteristics.
    - Process - components of the encounter.
    - Outcomes - patient's subsequent health status.
    Five methods by which quality can be assessed on the basis of process data, outcome data, or both:
    - Implicit - no prior standards or agreements about what reflects good or poor qualioty:
    - 1. Process - was the process of care adequate?
    - 2. Outcome - could better care have improved the outcome?
    - 3. Considering both process and outcome of care, was overall quality of care acceptable?
    - 4. Explicit process criteria.
    - 5. Explicit outcomes criteria.
    Agency for Health Care Policy and Research (AHCPR) (name changed in 1999 to Agency for Healthcare Reasearch and Quality (AHRQ)) : literature reviews and expert opinion to establish guidelines for care and quality of care criteria.

  21. Chassin MR. Quality of Health Care Part 3 of 6: Improving the Quality of Care. New England Journal of Medicine 1996; 335(14):1060-1063.
    Notes: Explores improving quality of care.
    After more than two decades of preoccupation with the costs of health care, more attention is being devoted to quality of care. Quality of care discussions now coming from employers, managed care organizations and insurers, newspapers, The Health Care Finance Administration (HCFA) and The Joint Commission on Accreditation of Healthcare Organizations (JCAHO).
    - 1960's: access to care (for specific populations - poor and elderly).
    - 1970's: peer review.
    - 1980's: quality assuarance.
    - 1990's: quality improvement - marketplace competition - report cards.
    Skepticism about quality improvement:
    - little difference between new and old
    - little evidence of improved outcomes
    - quality improvment for cost containment
    Need for new approaches to quality improvement
    - meta anlyses, improvements, increasing numbers
    - consensus guidelines meeting criteria of Institute of Medicine 1990, 1992 recommendations
    Quality improvement and better outcomes for pataients
    - faulty systems responsible of errors

  22. Pestotnik SL, Classen DC, Evans RS, Burke JP. Implementing Antibiotic Practice Guidelines through Computer-Assisted Decision Support: Clinical and Financial Outcomes. Ann Intern Med 1996; 124(10):884-890.
    Abstract: Objective: To determine the clinical and financial outcomes of antibiotic practice guidelines implemented through computer-assisted decision support. Design: Descriptive epidemiologic study and financial analysis. Setting: 520-bed community teaching hospital in Salt Lake City, Utah. Patients: All 162 196 patients discharged from LDS Hospital between 1 January 1988 and 31 December 1994. Intervention: An antibiotic management program that used local clinician-derived consensus guidelines embedded in computer-assisted decision support programs. Prescribing guidelines were developed for inpatient prophylactic, empiric, and therapeutic uses of antibiotics. Measurements: Measures of antibiotic use included timing of preoperative antibiotic administration and duration of postoperative antibiotic use. Clinical outcomes included rates of adverse drug events, patterns of antimicrobial resistance, mortality, and length of hospital stay. Financial and use outcomes were expressed as yearly expenditures for antibiotics and defined daily doses per 100 occupied bed-days. Results: During the 7-year study period, 63 759 hospitalized patients (39.3%) received antibiotics. The proportion of the hospitalized patients who received antibiotics increased each year, from 31.8% in 1988 to 53.1% in 1994. Use of broad-spectrum antibiotics increased from 24% of all antibiotic use in 1988 to 47% in 1994. The annual Medicare case-mix index increased from 1.7481 in 1988 to 2.0520 in 1993. Total acquisition costs of antibiotics (adjusted for inflation) decreased from 24.8% ($987 547) of the pharmacy drug expenditure budget in 1988 to 12.9% ($612 500) in 1994. Antibiotic costs per treated patient (adjusted for inflation) decreased from $122.66 per patient in 1988 to $51.90 per patient in 1994. Analysis using a standardized method (defined daily doses) to compare antibiotic use showed that antibiotic use decreased by 22.8% overall. Measures of antibiotic use and clinical outcomes improved during the study period. The percentage of patients having surgery who received appropriately timed preoperative antibiotics increased from 40% in 1988 to 99.1% in 1994. The average number of antibiotic doses administered for surgical prophylaxis was reduced from 19 doses in the base year to 5.3 doses in 1994. Antibiotic-associated adverse drug events decreased by 30%. During the study, antimicrobial resistance patterns were stable, and length of stay remained the same. Mortality rates decreased from 3.65% in 1988 to 2.65% in 1994 (P less than 0.001). Conclusions: Computer-assisted decision support programs that use local clinician-derived practice guidelines can improve antibiotic use, reduce associated costs, and stabilize the emergence of antibiotic-resistant pathogens
    Web Site:

  23. Bodenheimer T. The American Health Care System: The Movement for Improved Quality in Health Care. New England Journal of Medicine 1999; 340(6):488-492.

  24. Institue of Medicine (IOM) Health Care Services. To Err Is Human: Building a Safer Health System. National Academy Press, 1999.

  25. Institute of Medicine (IOM) National Care Policy Board. Ensuring Quality Cancer Care. National Academy Press, 1999.

  26. Institue of Medicine (IOM) Health Care Services. Crossing the Quality Chasm: A New Health System for the 21st Century. National Academy Press, 2001.

  27. Anderson L, Reece RL. MaineHealth Helps Physicians Improve Chronic Disease Care. The Quality Indicator 2003;3-5.
    Web Site:
    Link to Full Text:

  28. Gaede P, Vedel P, Larsen N, Jensen GVH, Parving HH, Pedersen O. Multifactorial Intervention and Cardiovascular Disease in Patients with Type 2 Diabetes. N Engl J Med 2003; 348(5):383-393.
    Abstract: Background Cardiovascular morbidity is a major burden in patients with type 2 diabetes. In the Steno-2 Study, we compared the effect of a targeted, intensified, multifactorial intervention with that of conventional treatment on modifiable risk factors for cardiovascular disease in patients with type 2 diabetes and microalbuminuria. Methods The primary end point of this open, parallel trial was a composite of death from cardiovascular causes, nonfatal myocardial infarction, nonfatal stroke, revascularization, and amputation. Eighty patients were randomly assigned to receive conventional treatment in accordance with national guidelines and 80 to receive intensive treatment, with a stepwise implementation of behavior modification and pharmacologic therapy that targeted hyperglycemia, hypertension, dyslipidemia, and microalbuminuria, along with secondary prevention of cardiovascular disease with aspirin. Results The mean age of the patients was 55.1 years, and the mean follow-up was 7.8 years. The decline in glycosylated hemoglobin values, systolic and diastolic blood pressure, serum cholesterol and triglyceride levels measured after an overnight fast, and urinary albumin excretion rate were all significantly greater in the intensive-therapy group than in the conventional-therapy group. Patients receiving intensive therapy also had a significantly lower risk of cardiovascular disease (hazard ratio, 0.47; 95 percent confidence interval, 0.24 to 0.73), nephropathy (hazard ratio, 0.39; 95 percent confidence interval, 0.17 to 0.87), retinopathy (hazard ratio, 0.42; 95 percent confidence interval, 0.21 to 0.86), and autonomic neuropathy (hazard ratio, 0.37; 95 percent confidence interval, 0.18 to 0.79). Conclusions A target-driven, long-term, intensified intervention aimed at multiple risk factors in patients with type 2 diabetes and microalbuminuria reduces the risk of cardiovascular and microvascular events by about 50 percent
    Web Site:

  29. McGlynn EA, Asch SM, Adams J et al. The Quality of Health Care Delivered to Adults in the United States. N Engl J Med 2003; 348(26):2635-2645.
    Abstract: Background We have little systematic information about the extent to which standard processes involved in health care -- a key element of quality -- are delivered in the United States. Methods We telephoned a random sample of adults living in 12 metropolitan areas in the United States and asked them about selected health care experiences. We also received written consent to copy their medical records for the most recent two-year period and used this information to evaluate performance on 439 indicators of quality of care for 30 acute and chronic conditions as well as preventive care. We then constructed aggregate scores. Results Participants received 54.9 percent (95 percent confidence interval, 54.3 to 55.5) of recommended care. We found little difference among the proportion of recommended preventive care provided (54.9 percent), the proportion of recommended acute care provided (53.5 percent), and the proportion of recommended care provided for chronic conditions (56.1 percent). Among different medical functions, adherence to the processes involved in care ranged from 52.2 percent for screening to 58.5 percent for follow-up care. Quality varied substantially according to the particular medical condition, ranging from 78.7 percent of recommended care (95 percent confidence interval, 73.3 to 84.2) for senile cataract to 10.5 percent of recommended care (95 percent confidence interval, 6.8 to 14.6) for alcohol dependence. Conclusions The deficits we have identified in adherence to recommended processes for basic care pose serious threats to the health of the American public. Strategies to reduce these deficits in care are warranted
    Web Site:

  30. Steinberg EP. Improving the Quality of Care -- Can We Practice What We Preach? N Engl J Med 2003; 348(26):2681-2683.
    Web Site:

  31. Centers for Medicare & Medicaid Services (CMS). Physician Focused Quality Initiative (PFQI): Chronic Disease and Prevention Measures. <[11] Journal> <[05] Pub Date>;(<[15] Issue>).
    Web Site:

  32. Centers for Medicare & Medicaid Services (CMS). CMS Doctor's Office Quality Project (DOQ) Overview

  33. Epstein AM, Lee TH, Hamel MB. Paying Physicians for High-Quality Care. New England Journal of Medicine 2004; 350(4):406-410.

  34. Gordon, M. S., DuMoulin, J. P., and Medical Service Committee. Patient-Centered, Physician-Guided Care for the Chronically Ill: The American College of Physicians Prescription for Change. <[11] Journal> 2004; <[12] Volume>.

  35. Gorman, R and Health and Public Policy Committee. The Use of Performance Measurements to Improve Physician Quality of Care. <[11] Journal> 4-19-2004; <[12] Volume>.

  36. Agency for Healthcare Research and Quality (AHRQ). Ambulatory Care Quality Alliance Recommended Starter Set: Clinical Performance Measures for Ambulatory Care. <[11] Journal> <[05] Pub Date>;(<[15] Issue>).
    Web Site:

  37. Baron RJ, Fabens EL, Schiffman M, Wolf E. Electronic Health Records: Just around the Corner? Or over the Cliff? Ann Intern Med 2005; 143(3):222-226.
    Abstract: We recently implemented a full-featured electronic health record in our independent, 4-internist, community-based practice of general internal medicine. We encountered various challenges, some unexpected, in moving from paper to computer. This article describes the effects that use of electronic health records has had on our finances, work flow, and office environment. Its financial impact is not clearly positive; work flows were substantially disrupted; and the quality of the office environment initially deteriorated greatly for staff, physicians, and patients. That said, none of us would go back to paper health records, and all of us find that the technology helps us to better meet patient expectations, expedites many tedious work processes (such as prescription writing and creation of chart notes), and creates new ways in which we can improve the health of our patients. Five broad issues must be addressed to promote successful implementation of electronic health records in a small office: financing; interoperability, standardization, and connectivity of clinical information systems; help with redesign of work flow; technical support and training; and help with change management. We hope that sharing our experience can better prepare others who plan to implement electronic health records and inform policymakers on the strategies needed for success in the small practice environment
    Web Site:

  38. Basch P. Electronic Health Records and the National Health Information Network: Affordable, Adoptable, and Ready for Prime Time? Ann Intern Med 2005; 143(3):227-228.
    Web Site:

  39. Dudley RA. Pay-for-Performance Research: How to Learn What Clinicians and Policy Makers Need to Know. JAMA: The Journal of the American Medical Association 2005; 294(14):1821-1823.
    Web Site:

  40. Hillestad R, Bigelow J, Bower A et al. Can electronic medical record systems transform health care? Potential health benefits, savings, and costs. Health Aff (Millwood ) 2005; 24(5):1103-1117.
    Abstract: To broadly examine the potential health and financial benefits of health information technology (HIT), this paper compares health care with the use of IT in other industries. It estimates potential savings and costs of widespread adoption of electronic medical record (EMR) systems, models important health and safety benefits, and concludes that effective EMR implementation and networking could eventually save more than $81 billion annually-by improving health care efficiency and safety-and that HIT-enabled prevention and management of chronic disease could eventually double those savings while increasing health and other social benefits. However, this is unlikely to be realized without related changes to the health care system
    Web Site: PM:16162551
    Notes: DA - 20050915
    IS - 0278-2715
    LA - eng
    PT - Journal Article
    SB - IM

  41. Himmelstein DU, Woolhandler S. Hope and hype: predicting the impact of electronic medical records. Health Aff (Millwood ) 2005; 24(5):1121-1123.
    Abstract: The current fascination with electronic medical records (EMRs) is not new. For decades, vendors have capitalized on this enthusiasm. But hospitals and clinics have ended up with little to show for their large outlays. Indeed, computing at a typical hospital has not gotten much beyond what was available twenty-five years ago. The RAND analysis continues the tradition of hope and hype. Unfortunately, behind their impressive predictions of savings lie a disturbing array of unproven assumptions, wishful thinking, and special effects
    Web Site: PM:16162553
    Notes: DA - 20050915
    IS - 0278-2715
    LA - eng
    PT - Journal Article
    SB - IM

  42. Iglehart JK. Pursuing Health IT: The Delicate Dance Of Government And The Market. Health Aff (Millwood ) 2005; 24(5):1100-1101.
    Web Site: PM:16162549
    Notes: DA - 20050915
    IS - 0278-2715
    LA - eng
    PT - Journal Article
    SB - IM

  43. Iglehart JK. Linking Compensation to Quality -- Medicare Payments to Physicians. N Engl J Med 2005; 353(9):870-872.
    Web Site:

  44. Leape LL, Berwick DM. Five Years After To Err Is Human: What Have We Learned? JAMA: The Journal of the American Medical Association 2005; 293(19):2384-2390.
    Abstract: Five years ago, the Institute of Medicine (IOM) called for a national effort to make health care safe. Although progress since then has been slow, the IOM report truly "changed the conversation" to a focus on changing systems, stimulated a broad array of stakeholders to engage in patient safety, and motivated hospitals to adopt new safe practices. The pace of change is likely to accelerate, particularly in implementation of electronic health records, diffusion of safe practices, team training, and full disclosure to patients following injury. If directed toward hospitals that actually achieve high levels of safety, pay for performance could provide additional incentives. But improvement of the magnitude envisioned by the IOM requires a national commitment to strict, ambitious, quantitative, and well-tracked national goals. The Agency for Healthcare Research and Quality should bring together all stakeholders, including payers, to agree on a set of explicit and ambitious goals for patient safety to be reached by 2010
    Web Site:

  45. Rosenthal MB, Frank RG, Li Z, Epstein AM. Early Experience With Pay-for-Performance: From Concept to Practice. JAMA: The Journal of the American Medical Association 2005; 294(14):1788-1793.
    Abstract: Context The adoption of pay-for-performance mechanisms for quality improvement is growing rapidly. Although there is intense interest in and optimism about pay-for-performance programs, there is little published research on pay-for-performance in health care. Objective To evaluate the impact of a prototypical physician pay-for-performance program on quality of care. Design, Setting, and Participants We evaluated a natural experiment with pay-for-performance using administrative reports of physician group quality from a large health plan for an intervention group (California physician groups) and a contemporaneous comparison group (Pacific Northwest physician groups). Quality improvement reports were included from October 2001 through April 2004 issued to approximately 300 large physician organizations. Main Outcome Measures Three process measures of clinical quality: cervical cancer screening, mammography, and hemoglobin A1c testing. Results Improvements in clinical quality scores were as follows: for cervical cancer screening, 5.3% for California vs 1.7% for Pacific Northwest; for mammography, 1.9% vs 0.2%; and for hemoglobin A1c, 2.1% vs 2.1%. Compared with physician groups in the Pacific Northwest, the California network demonstrated greater quality improvement after the pay-for-performance intervention only in cervical cancer screening (a 3.6% difference in improvement [P = .02]). In total, the plan awarded $3.4 million (27% of the amount set aside) in bonus payments between July 2003 and April 2004, the first year of the program. For all 3 measures, physician groups with baseline performance at or above the performance threshold for receipt of a bonus improved the least but garnered the largest share of the bonus payments. Conclusion Paying clinicians to reach a common, fixed performance target may produce little gain in quality for the money spent and will largely reward those with higher performance at baseline
    Web Site:

  46. Walker JM. Electronic medical records and health care transformation. Health Aff (Millwood ) 2005; 24(5):1118-1120.
    Abstract: Effective electronic medical care record (EMR) systems will make a critical contribution to health care transformation. However, we need to know more about the total costs of EMRs and the ways in which they will interact with existing health care systems to make compelling predictions about their clinical benefits or the savings they can enable
    Web Site: PM:16162552
    Notes: DA - 20050915
    IS - 0278-2715
    LA - eng
    PT - Journal Article
    SB - IM