Health IT Enabled Quality Improvement: A Vision for Better Health and Health Care

Today we are pleased to publish Health IT Enabled Quality Improvement: A Vision to Achieve Better Health and Health Care. This paper describes ONC’s vision for advancing the use of health IT to support transformational improvement in health care quality and value.  It invites health IT stakeholders – clinicians, consumers, hospitals, public health, technology developers, payers, researchers, policymakers and many others – to join ONC in shaping the future with a renewed focus on health and care quality as the “why” that aligns with the “what” of interoperable health information systems.

What are we talking about?

Quality measurement has a long tradition in health care.  The National Committee for Quality Assurance (NCQA), National Quality Forum (NQF), The Joint Commission, the Centers for Medicare & Medicaid Services (CMS) and others have long track records of creating and maintaining quality programs that have enabled care delivery organizations to identify gaps in care quality, and to define and motivate organizations toward best practice.  But measurement is only one part of an improvement program.  We don’t improve drivers’ alignment with the speed limit (and therefore the safety of drivers and pedestrians) by giving tickets, or by mailing notices days, weeks or months later.  Rather, real-time feedback loops work to improve the quality of the driving as the driving is being done!  New technology being applied to driving include notifications or even corrective action when the driver drifts out of unanticipated object lane, comes to close to another car, or encounters an unanticipated object while driving in reverse.

A “quality report” delivered to a hospital, practice or care provider about how they performed in the past will likewise have only limited (if any) effect on quality improvement, just as giving students mediocre grades doesn’t help students do better in the future.

As Thomas Goetz describes External Links Disclaimer, a feedback loop requires four components:

First comes the data: A behavior must be measured, captured, and stored. This is the evidence stage. Second, the information must be relayed to the individual, not in the raw-data form in which it was captured but in a context that makes it emotionally resonant. This is the relevance stage. But even compelling information is useless if we don’t know what to make of it, so we need a third stage: consequence. The information must illuminate one or more paths ahead. And finally, the fourth stage: action.

The medical informatics community has worked for nearly thirty years on decision support functionality in health information technology.  Historically, CDS (Clinical Decision Support) and CQM (Clinical Quality Measures) have been developed using different tools, by different technical teams, with different expertise, and different (but convergent) goals.  CDS developers have generally had explicit clinical goals: preventing unsafe prescriptions, alerting clinicians to missed care delivery opportunities, notifying providers of abnormal laboratory results, and many other clinical optimizations.  These two communities have been performing this parallel play External Links Disclaimer for decades, and while CDS and CQM have the same goals, (perfect care delivery – the highest quality care for all) their methods, technical tools, and standards have heretofore been disconnected from each other.  We need to change that.  We need to change the conversation from “CDS” or “CQM” and start talking as one community with an aligned focus of quality improvement.  This is one set of work, one community, one set of technical standards, and one mission:  CQI – Clinical Quality Improvement.


Just as the building blocks of interoperability are interdependent and progress must be incremental across all of them over the next decade, we offer the Health IT Enabled Quality Improvement vision as part of this same journey toward a converged emphasis on improvement of care quality – the sum of CDS and CQM.  In order to get there from here External Links Disclaimer, we need to:

  • use the same technical standards;
  • strategically use certification and testing to assure users that improvement tools do what they need to do;
  • incorporate the same strong privacy and security protections for individuals’ health information;
  • foster business, clinical, and regulatory environments that support both the development of effective, user-friendly quality improvement tools and the appropriate exchange and use of health information to support easy use of those tools; and
  • develop rules of engagement and governance that facilitate availability and use of quality improvement functions and the information on which they will rely.

ONC cannot achieve the health IT enabled quality improvement vision alone. We will work collaboratively and transparently with stakeholders to develop shared national goals for three, six and ten-year timeframes that will serve as milestones on our shared journey to achieve this vision as an integral part of the nation’s future.  As always, we welcome your feedback – both positive and negative.


  1. Barry Blumenfeld says:

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  2. Jerry Osheroff says:

    Excellent and important points in the document – e.g., linking QM and QI/CDS, need for multi-stakeholder engagement, and Vision for the Future section – including QI Ecosystem in Fig 2.

    Very surprised though that the “How will We Get There” section doesn’t say much more about the critical and difficult ‘people’ and ‘process’ work needed to achieve the vision.

    This omission is especially striking given important, recent ONC efforts to advance CDS-enabled QI – particularly in the ‘process’ realm. This work includes the CMS CDS/QI tipsheet (, the ONC Resources for Improving Care with CDS (, and the EHR Innovations for Hypertension Challenge (

    Given the centrality of ‘coordination’ in ONC’s name and mission, hopefully follow-on work to this paper will better connect important HIT/QI ‘people and process’ dots within ONC’s domain, and its work with partners on the HIT-enabled QI journey.

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