Data Gathering Efforts

The current measurement enterprise is characterized by multiple initiatives across the many dimensions of the health system, with little alignment of measures or goals. Given the proliferation of measures in play, a key challenge is harmonizing and aligning measurement programs to minimize redundancies and unnecessary customization (Hussey et al., 2009; IOM, 2006; NQF, 2013; Wold, 2008). The collection and analysis of measures require significant effort, time, and resources; therefore, it is important to ensure that measurement produces the maximum amount of information for the least amount of investment in resources. Similarly, significant opportunity costs are entailed in devoting resources to inefficient, redundant, or poorly specified measurement activities, which can displace other valuable opportunities to improve health and health care. The appendixes of this report provide widely ranging examples of measurement activities, reporting requirements, and data sources that support measurement of different aspects of the health system. Yet while more than 27 organizations, 36 programs, and 1,235 individual measures are identified, they represent only a portion of the measurement activities under way.

In addition to the sheer number of measures, another challenge lies in their focus. Many measurement programs limit their focus to narrow or technical components of health care processes instead of targeting outcomes. Health care measures also often fail to capture the multiple factors that lie outside the domain of the traditional health care system but represent the most important influences on health (IOM, 2011b, 2013b; Kindig and Stoddart, 2003; McGinnis and Foege, 1993; McGinnis et al., 2002). Without understanding these factors, it will be difficult to make sustainable progress toward improving the health of the nation.

Measurement Requirements

An increasing number of organizations require health care providers and others to report data on a variety of measures. These contractual requirements range from long-standing government programs, such as the reporting of vital statistics, to requirements related to specific programs, such as the Medicare Shared Savings Program for accountable care organizations (ACOs) or incentive payments for the Physician Quality Reporting System (PQRS). Reporting requirements often are aimed at assessing similar features and targets, such as readmission rates or costs of care, but with differently structured and implemented measures. As a result, hospitals and other health care organizations often are required to report redundant and overlapping measures, which imposes an additional time and resource burden. A detailed overview of major reporting requirements and their similarities and differences is provided in Appendix B.

Despite the call by organizations such as NQF and HHS for greater alignment and harmonization in health system measurement, the various measurement efforts remain broadly uncoordinated both horizontally, or across various activities, and vertically, in terms of consistent and comparable measurements at the national, state, local, and institutional levels. The Committee believes that renewed attempts to align and harmonize measures to reduce redundancies and inefficiencies may now succeed because of the significant changes that have occurred in the environment for measurement. Notably, data capture capabilities have grown rapidly, with electronic health records and other digital tools seeing increasingly widespread use (IOM, 2011a). The emerging health information technology infrastructure could support a real-time measurement system for the routine collection of information about care processes, patient needs, progress toward health goals, and individual and community health outcomes. The transformation of technology and capacity provides an opportunity to measure what matters most, enabling goals to drive measures rather than measures driving goals.

Healthy People

The foundational motivation of this report, and of the health system at large, is improving the health of individuals, communities, and the nation. From a population health perspective, the United States faces significant challenges, with chronic disease afflicting nearly half of all adults, violence and injury being the leading cause of death for people aged 1 to 44, and childhood obesity—a harbinger of poor health in adulthood—affecting 17 percent of America's children (CDC, 2012; Ogden et al., 2014; Ward and Schiller, 2013). From an international perspective, the United States is below average on a range of health measures. The nation spends nearly twice the OECD average on health, yet Americans have a life expectancy of 78.7 years, below the OECD average of 80.2 years (OECD, 2013). The National Research Council (NRC)/IOM report U.S. Health in International Perspective: Shorter Lives, Poorer Health provides a broad look at the state of the nation's health in comparison with other nations (NRC and IOM, 2013). A key finding in that report is that Americans fare worse than other developed nations in at least nine health areas: infant mortality and low birth weight, injuries and homicides, adolescent pregnancy and sexually transmitted infections, HIV and AIDS, drug-related deaths, obesity and diabetes, heart disease, chronic lung disease, and disability. Among the contributors to this American disadvantage are limitations in access to care, disparate quality of care delivered by the nation's health systems, risky health behavior profiles, and socioeconomic disparities (NRC and IOM, 2013).

The U.S. health system is marked by significant challenges beyond the delivery of care in hospitals or provider offices. Such factors as socioeconomic status, behavior, environment, and health literacy have important implications for the health of individuals and communities. It is estimated that in the United States, 10 to 15 percent of preventable mortality is amenable to health care interventions, while approximately 40 percent of preventable deaths are attributable to behavior patterns that could potentially be modified (McGinnis et al., 2002). Paradoxically, it is estimated that 95 percent of U.S. spending on health goes to direct provision of health services, with the remaining 5 percent being spent on public health (McGinnis et al., 2002). While spending on health care is significantly higher in the United States than in other developed countries, the nation spends less, as a proportion of total spending, on public health and social programs that address those aspects of health outside of clinical care (Bradley et al., 2011). The IOM report For the Public's Health: Investing in a Healthier Future explores in detail the state of America's public health system and financing, and presents a case for reformulating the nation's portfolio of health investments to focus more resources on public health and prevention as a step toward improving health and reducing health care costs in the United States (IOM, 2012b).

Care Quality

A major impetus for transforming the measurement enterprise is the uneven performance of the health system, which is characterized by islands of excellence existing alongside areas in need of improvement. On the one hand, significant advances have been made in improving the public health. During the 20th century, life expectancy increased by nearly 60 percent (Guyer et al., 2000), while the mortality rate has declined by more than 60 percent over the past 75 years (Hoyert, 2012). Clinical care also has seen marked progress, including vaccines that have virtually eliminated many childhood infectious diseases; antibiotic therapies for infectious diseases; multiple interventions for cardiovascular disease, from beta blockers to percutaneous coronary intervention (PCI) and coronary artery bypass grafting; and cocktails of pharmaceutical agents tailored to the specific genetic characteristics of HIV, a microbe identified just 30 years ago (Fauci, 2003; FDA, 2011; Fischl et al., 1987; IOM, 2012a; Nabel and Braunwald, 2012; Simon et al., 2006).

At the same time, the system has compelling needs for improvement. A decade ago, in the report To Err Is Human: Building a Safer Health System, the IOM estimated that 44,000 to 98,000 people died in hospitals every year as a result of preventable medical errors (IOM, 1999). Medical errors remain common, occurring in almost one-third of hospitalized patients (Classen et al., 2011; Landrigan et al., 2010; Levinson, 2010, 2012). One recent analysis suggests that preventable harm may lead to more than 200,000 deaths per year (James, 2013). In addition, applicable research and evidence are not integrated routinely into direct patient care, with Americans receiving only about half of the care recommended by current evidence (McGlynn et al., 2003) and with a lag of years or even decades in the application of new evidence to current health practice (IOM, 2012a).

The care system also faces significant challenges in terms of access to care, with many Americans encountering limitations due to cost, transportation, wait times, and other factors that can impede their ability to receive the care they need at the right time and place. Relatedly, the care received often is limited in the extent to which it meets and accounts for the needs, priorities, and perspectives of patients.

Health care also has become increasingly complex, resulting in shortcuts in decision making and clinical processes, fragmentation of care, preventable errors, and a lack of accountability. Moreover, the health care system is characterized by inefficiencies in spending and resource use, such that an estimated 30 percent of health care spending is wasted. The 2012 IOM report Best Care at Lower Cost explores the causes and consequences of shortfalls in health care quality and outlines approaches for addressing them (IOM, 2012a).

Care Costs

The relative underperformance of the health system with respect to population health and health care quality has coincided with growth in health care costs that has vastly outpaced the rest of the economy, highlighting the lower levels of productivity being achieved by the health system (IOM, 2010, 2012a). Health care costs now constitute almost a fifth of the nation's economy (Hartman et al., 2013) and pose a challenge for the budgets of the federal and state governments, businesses, and families. Costs vary significantly and with little correlation with quality among different regions of the country, states, localities, and even clinicians operating in the same practice (IOM, 2013c). Health care expenditures sometimes are only coincidentally related to care outcomes.

The costs of health care in the United States for individuals, states, and the nation pose significant challenges for the accessibility and affordability of care and raise questions as to whether the care being purchased is worth the investment. Growth in aggregate health care costs challenges the competiveness of U.S. companies and reduces take-home pay for working Americans. High out-of-pocket costs place financial pressure on individuals and families, potentially leading people to avoid or delay care or to ration personal care resources by, for example, taking medications less frequently than prescribed (Goldman et al., 2004). Health care also is a significant source of debt for many Americans (Doty et al., 2005), while health care costs are the major contributor to growth in the national debt. And demands placed on state and national budgets by health care costs may drive down investment in other critical areas impacting health, including education and the environment (McCullough et al., 2012). Although some recent trends in health care costs have been encouraging, with the pace of increases remaining lower than expected, the precise cause of this effect and whether it will continue over time are unclear (Blumenthal et al., 2013; Cutler and Sahni, 2013; Ryu et al., 2013).

Moving forward, how will the nation know whether its investments in the health care system are improving health and yielding a higher quality of life for its citizens? While the current measurement system evaluates many aspects of health care delivery, little attention is paid to measurement of the “value” of health care—better health outcomes per unit cost. No single measure of value exists, and improvements in quality or outcomes and in cost often are measured using different scales. In the absence of quality information, people tend to equate higher cost with higher quality. Moreover, different people may assign different weight to various aspects of quality—for example, expected mobility versus length of recovery time or anticipated risk. Information should enable care choices and treatment that best match individual priorities. From a consumer perspective, therefore, price is a poor indicator of quality and, by extension, not a useful data point for choosing among services or providers. Unlocking the power of the demand side—people, patients, employers, families, and government programs—to drive progress in the health system will depend on the provision of meaningful, accurate, and comparable information about value.

People's Engagement in Health and Health Care

In the context of legislative and payment reforms, changes in technology and access to information, new models of care delivery, and links between progress in chronic disease and patient initiative, patients, consumers, and the broader public are playing an increasing role in health and health care. Evidence suggests that people who are more actively involved with their health and health care may have improved outcomes. Research has found that people who use health-related social networking sites, such as PatientsLikeMe, TuDiabetes, and TheBody, have improved treatment adherence and a better understanding of their medical condition and feel more in control of their disease management (Grajales et al., 2014). One survey conducted in partnership with Consumer Reports found that American social media users have a high level of interest in sharing their personal data to improve the evidence base, assuming adequate privacy protections are in place. Fully 94 percent of people participating in the survey reported being willing to share their health data to help doctors improve care (Grajales et al., 2014).

Importantly, the concept of engagement pertains both to individuals and to the community. Individuals and communities share responsibility for maintaining and promoting the health of individuals and populations. Effective engagement is built on public understanding of the determinants of health. Similarly important is that determinants of health be reflected in public agendas for health improvement, which demonstrate the extent of a community's commitment to addressing the population-wide factors in the community that shape people's health, health care, and health prospects. While the evidence base is still evolving in this domain as it is in the domains of healthy people, care quality, and care costs, an effective strategy for marshaling greater individual and public engagement in health and health care is needed.

The Changing Measurement Landscape

Rapid change in the organizational and payment landscapes for health care has introduced new measurement responsibilities. Moreover, the introduction of multiple new models for delivering, paying for, and organizing health care has coincided with new initiatives to improve personal and population health. Developments range from ACOs, insurance marketplaces, and value-based payment programs to regional and community health improvement collaboratives. These new models and initiatives are not adequately supported by current assessment capabilities; better measurement tools are needed to support their operations and capture their successes (Schneider et al., 2011). Furthermore, the lack of alignment and comparability in the current measurement landscape limits the capacity to make meaningful comparisons among approaches or solutions and, by extension, may limit the spread of best practices and solutions for widely shared health system challenges.

Increasingly Burdensome Measurement Requirements

Tremendous growth in the development and use of measurement in the health system has led to a large number and variety of measures that, although in many cases of high quality, may create significant areas of overlap or redundancy. Health care organizations report rapidly growing requirements for the devotion of staff time and money—particularly clinician time—for measurement requirements of marginal utility in improving care and outcomes (Meyer et al., 2012). The burden of so many measurement activities and requirements can have negative consequences in terms of both the real cost of inefficiency in data collection and reporting and the opportunity costs associated with excessive spending on measurement. The growth of the measurement burden is discussed in greater detail in Chapter 2 as a key challenge for health and health care measurement.

A Blurred Focus on Priority Issues

New knowledge, alternative care delivery vehicles, the development of new incentive approaches for providers, expanded public input, and other factors are intersecting to drive rapid change in the health system. Most of these changes, however, occur in an independent and uncoordinated fashion, and the introduction of each new measure for assessing their results and outcomes tends to diffuse the ability to focus on what is most important. Fragmentation of the system leads to fragmentation of solutions, with different stakeholder groups and institutions working toward different goals with different tools and measures. For example, one study found that more than 30 percent of measures surveyed were either modifications of existing measures or homegrown, with 80 percent of programs modifying at least one measure and 40 percent of programs creating at least one new measure (Bazinsky and Bailit, 2013). This lack of coordination blurs focus, at every level, on the priority issues and outcomes with the greatest potential to improve health.

Lack of Standardization in Measuring Similar Concepts

The growth over the past decade in measures that health care organizations are required to report is due in part to redundancies and inefficiencies in data collection and measure specification, such that different organizations interested in assessing the same target or feature require different measures with different specifications. For example, one study found that across six HHS measurement programs, 61 different measures were in use for smoking cessation, 113 for HIV, 19 for obesity, and 68 for perinatal health (HHS, 2014). The result is a health measurement system that lacks standardization for the assessment and reporting of data on commonly assessed concepts.

Need for a Core Measure Set

A set of core measures is needed to promote improved health and health care. As defined in Box 1-2, core measures, for present purposes, consist of a parsimonious set of measures that provide a quantitative indication of current status on the most important elements in a given field, and that can be used as a standardized and accurate tool for informing, comparing, focusing, monitoring, and reporting change. A core measure set is not intended to replace the full range of measures in use today, rather, it is intended to enhance the focus of central health care actors on critical goals and routes toward those goals. A core measure set has the potential to accelerate improvement by concentrating attention, reducing inefficiency, making reporting more powerful, and promoting innovation in measurement and care. In other words, a well-designed core measure set can lead to better health care at lower cost.

BOX 1-2

Definition of Core Measures. A parsimonious set of measures that provide a quantitative indication of current status on the most important elements in a given field, and that can be used as a standardized and accurate tool for informing, comparing, focusing, (more...)

As detailed above, while the ability to measure discrete processes and features in health care has grown increasingly sophisticated, the availability of measures and data to enable direct comparisons of broader health outcomes and circumstances at the national, state, county, community, and institutional levels is a persistent challenge. Core measures present an opportunity to improve the nation's ability to measure and improve performance on health, health care, affordability, and engagement by providing common points around which activities can be oriented and outcomes compared. By virtue of their central nature, core measures can drive improvements that will have a ripple effect on performance throughout the system; that is, if stakeholders align around a common set of well-designed measures, attention to improvement on those measures can lead to system-wide performance enhancement. The existence of a parsimonious core measure set also can free institutions to direct additional measurement focus and resources to issues tailored to their particular circumstances.

Relevance to Diverse Health Care Roles and Circumstances

To serve their purpose of focusing attention on overriding health care and health goals, core measures must be broad-based and high-level; they cannot, by definition, capture the particular concerns and perspectives of each actor in the health system, regardless of the validity and compelling nature of those interests. Nevertheless, the Committee believes that core measures are relevant to the work of virtually all stakeholders involved in advancing the health and health care of individuals and communities nationwide, even where the work of those actors is quite specialized and may call for legitimate, complementary measure sets. Specialists in allergy and immunology, for example, may not immediately see their primary service activity directly reflected in the core measure set. However, their work is directly related to, and affected by, the profiles of their patients with respect to issues like well-being, healthy communities, preventive services, care access, evidence-based care, care math with patient goals, personal spending burden, and individual engagement.¹ Furthermore, a core measure set that includes indicators of community health may focus the attention of these providers on the environmental and cultural factors that can so heavily influence the burden of allergic and immunologic illness among their patients. This awareness, in turn, can foster the sense of a professional opportunity to help address those community-wide influences. The process used to implement core measures must account for the requirement to make these translations into terms relevant to the many diverse health care actors.

In many cases, core measures may also need to be translated in ways that reveal their relevance and utility for actors at different levels of the health care system. For example, while the proportion of gross domestic product devoted to care provides a national view of health care spending, the concept of population spending burden is pertinent at the state, local, and institutional levels. At the state and local levels, the burden of health care spending could be compared against overall budgets or economic output, or spending levels could be assessed relative to peer states or to a performance benchmark. At the level of health care institutions, for example, the measure of total cost of care and resource use could provide actionable information on spending in the context of providing care services.

Study Charge

To address the increasingly urgent need for a framework, measures, and principles around which the nation might transform the efficiency, effectiveness, and utility of the health and health care measurement enterprise, the IOM, with the support of three sponsoring organizations—Blue Shield of California Foundation, the California HealthCare Foundation, and the Robert Wood Johnson Foundation—appointed the Committee on Core Metrics for Better Health at Lower Cost. The charge to the Committee, presented in Box 1-3, was essentially to articulate basic measurement needs focused on what matters most across all levels of the health system; identify a parsimonious set of core measures in those areas; describe how these core measures should relate to, shape, and enhance broader measurement efforts throughout the health system; and suggest strategic approaches to implementation. The ultimate goal of the Committee's work was to spur widespread improvement in health and health care through a more aligned and efficient measurement system. The breadth of the Committee's charge reflected the extent of opportunities to achieve this goal.

BOX 1-3

Charge to the IOM Committee on Core Metrics for Better Health at Lower Cost. An ad hoc committee will conduct a study and prepare a report directed at exploring measurement of individual and population health outcomes and costs, identifying fragilities (more...)

Study Approach

The Committee convened to carry out this study comprised 21 individuals with a broad range of expertise, including health economics and policy, population health, health care delivery and safety net populations, state and community health improvement, health measurement, and information technology and data infrastructure, as well as individuals who understand the perspectives of health care payers and purchasers, clinicians, researchers, and patients and consumers. Committee members' biographies are presented in Appendix E.

Recognizing that success depends on concerted actions by all stakeholders in the system, the Committee sought input and feedback from a broad range of individuals and organizations. Staff contacted 126 leading health organizations to solicit their thoughts on the current state of measurement, challenges limiting its potential, and opportunities that could be transformative. The resources received from these organizations informed the Committee's deliberations on the needs and opportunities in the field. The Committee also held open sessions at three of four of its meetings, during which stakeholders and practitioners from various organizations with ties to health and health care measurement—such as NQF, NCQA, CMS, the Agency for Healthcare Research and Quality (AHRQ), the Centers for Disease Control and Prevention (CDC), and the Office of the Secretary of HHS—provided additional perspective and background. Organizations representing patient and consumer perspectives also provided important input for these discussions.

The Committee deliberated during four in-person meetings and multiple conference calls over 2013 and 2014. The Committee's overarching approach to identifying core measures is illustrated in Figure 1-1. Its initial deliberations focused on clarifying the scope of the study and gathering input, while later meetings focused on synthesizing conclusions and formulating recommendations that would move measurement forward. To accelerate its efforts, the Committee drew on related IOM work described below, particularly an earlier IOM workshop on the core measurement needs for better care, better health, and lower costs (IOM, 2013a). Furthermore, staff and Committee members reviewed the evidence related to measurement and case studies of measurement initiatives to inform the findings, conclusions, and recommendations presented in this report.

FIGURE 1-1

The Committee's approach to identifying the core measure set.

This report references and builds on the work of a wide range of other individuals and organizations devoted to addressing the nation's changing health and health care measurement needs. These include activities stewarded through the HHS Secretary, the Secretary's Prevention Agenda and Healthy People Leading Health Indicators, the National Quality Strategy, the Joint Commission, the Institute for Healthcare Improvement, and the organizations mentioned above (CMS, CDC, AHRQ, NQF, and NCQA). These and other measurement activities are discussed in Chapter 2.

Domains

The Committee's charge was to identify measures that best reflect healthy people, care quality, care costs, and people's engagement in health and health care. Implicit in that charge is the notion that while the foundational societal aspiration is healthy people, population health is a product of the dynamics in each of these vital and interrelated domains of influence on health. The goal of healthy people cannot be achieved without quality care or engaged people. Gains in the quality of care and population health cannot be sustained without affordable care. And care quality and affordability cannot be optimized without engaged people.

Key Elements

Facilitating progress within and among these domains of influence depends on how their component elements are addressed. Although they may be characterized in different ways and often are interrelated at some level, each of the key elements presented in Table 1-1 is central to progress in health and health care. Quality of life is a goal basic to every individual, and although length of life is not an immutable goal for every person at every stage of life, it is an accepted standard for the overall health of populations. It also is now well established that the health of populations is substantially shaped by factors outside of health care, including patterns of health-related behaviors and social circumstances such as physical environments and socioeconomic status. High-quality care is a function of the interplay among access to care, prevention, and appropriate treatment.

Core Measure Set

The Committee proposes the core measure set presented in Table 1-1. Each core measure focus identified by the Committee represents an important focus for action at the national, state, local, and even institutional levels.

Measure development and standardization were beyond the scope of the Committee's charge. However, to accelerate the development and application of a fully specified core measure set, the Committee has specified what in its judgment is the best currently available measure for each core measure focus. This measure set, while imperfect, represents in the Committee's view a powerful starting set of “vital signs” for tracking progress toward improved health and health care in the United States. The Committee believes further that the core measure set recommended herein comprises the vital signs on the status and progress of the nation's health and health care, that a single measure can be chosen or developed for each of the core measure foci within each domain of influence, and that the development of a standardized measure is essential for each focus. The Committee also believes that, when applied, attention to these core measure foci will have the multiplier effect of improving performance broadly throughout the health and health care organizations engaged in their use.

Development Priorities

As noted above, the Committee has not specified each core measure in detail because, with few exceptions, the collaborative process of definition and refinement needed to develop widely accepted and fully specified measures was beyond the resources and scope of this study. Standardized measurement approaches exist for life expectancy and overweight and obesity, but such refinement has not yet been accomplished for measures in many other key areas, such as well-being, addictive behavior, healthy communities, evidence-based care, spending burden, and individual and community engagement. This is particularly true for individual and community engagement measures. The Committee focused considerable discussion on this focus, reflecting the relatively nascent state of conceptual and technical development of measures in this field. Committee members' perspectives were divided on the question of whether the strength and precision of the definitions and measures available for engagement warranted their inclusion alongside the domains of health, care quality, and care cost. Still, there was strong sentiment within the Committee that individual and community engagement are significant determinants of health and health care, clearly working in service to and as elements in the success of activities directed at the Triple Aim of better health, better care, and lower costs. Nonetheless, considerable definitional and analytic work will be required to develop practical measures that can reliably capture the extent to which individuals are prepared for and engage in effective participation in health and health care planning, delivery, and improvement. Additionally, research is needed to explore how levers available for community-wide action are being employed effectively for improvement in matters of central importance to the health of the population. Given the identification of engagement as a domain in the Committee's statement of task and the acknowledgment within the Committee that engagement represents an important—if underdeveloped—element of the changing landscape of health, the Committee's deliberations were guided by the four domains of health, care quality, care cost, and engagement.

Best Current Measures

Because most of the core measure foci shown in Table 1-1 are not supported by standardized measures accessible for application at every level of the health system, the Committee also specified, and presents for consideration in Chapter 4, best current measures for the core measure foci. Examples include the use of childhood immunization as a best current measure of the delivery of preventive services and self-reported health status as an indicator of well-being. Many of these best current measures are currently imperfect because of limitations in scope, reliability, generalizability, or conceptual boundary and will require substantial work. For this reason, the Committee recommends in this report that, as stakeholders at various levels try out their own proxies for the core measure foci in the short term, the Secretary of HHS steward a broadly inclusive process to marshal the nation's experience and expertise in the development of the standardized set of core measure foci, see Chapter 5.

Related Priority Measures

The Committee recognized that, while ripple or multiplier effects are anticipated as a result of the use of the 15 core measure foci identified, those foci will not be sufficient to serve all of the interests of given organizations. To begin to address this challenge, the Committee also identified 39 “related priority measures” for consideration, presented in Chapter 4. These measures, together with the core measures, give a more detailed view of the health system and are sufficiently granular and specific to be actionable by stakeholders as needed for their particular circumstances. The Committee believes that, as with the core measure foci, specification and stewardship of standardized approaches ought also to be undertaken for these related measures, although as a follow-on activity to that for the core measure foci.

Disparities

The Committee presents in Chapter 4 and in discussion throughout this report data available for the core measure foci, and well beyond, that highlight the substantial disparities among subpopulations in the United States with respect to health status and health care. These include disparities based on race, ethnicity, income, education, gender, geography, and urban or rural location. In the aggregate, this issue represents one of the greatest single health and health care challenges to the nation. Accordingly, the Committee considered recommending the development of a separate core measure aimed specifically at disparities. Instead, because the issue is so pervasive, the Committee discusses disparities in conjunction with each core measure.

Implementation

The Committee emphasizes that the process of refining, applying, and implementing the core measures is fundamental to success. Although face validity was a central criterion in identifying each measure, these core measures will not implement themselves. A carefully designed effort under the stewardship of the HHS Secretary will be needed to focus the nation's attention in a manner that will accelerate progress across the board. Therefore, the Committee's recommendations place particular emphasis on the roles, responsibilities, and opportunities for implementation—the critical features and actions necessary to achieve adoption and application of the core measures. At the same time, the multilevel and broad-based features of the implementation activities identified by the Committee are also intended to reflect both content and processes that are as catalytic and open as possible.