and in some cases on a blend of federal and state requirements and initiatives.

The backbone of Medicare’s external quality review processes is the QIOs. The QIOs are engaged in some projects that employ common measures and methodologies across most or all states, and this approach is increasingly becoming the norm. Much of the quality-related data used by QIOs is abstracted from samples of paper medical records or culled from claims data—methods that will likely become obsolete as computerized patient-level data become more readily available. QIOs have limited experience in public reporting, although sizable resources are earmarked for this function in their Seventh Scope of Work. Contractual, cultural, organizational, and programmatic modifications will be required for the QIO program to continue playing a central role in the quality enhancement processes of Medicare and other government health care programs.

The challenges for state Medicaid and SCHIP programs will also be significant. Under the proposed restructuring, states will be asked to relinquish some flexibility and to work in partnership with each other and federal government representatives from the six programs to agree upon standardized performance measurement sets and to apply these standardized measures across their Medicaid and SCHIP programs. States have already worked with CMS, each other, and NCQA on the development of the Health Plan Employer Data and Information Set (HEDIS) standardized measures adapted for state Medicaid programs, and these measures are being used for health plans with a good deal of uniformity in adoption and application. What is being sought here is a much stronger commitment to standardized measurement and reporting.

Third, strong support from the appropriate authorization and appropriations committees of Congress will be critical to success. Federal financial assistance to providers will be essential to establishing the necessary information technology infrastructure. AHRQ will require additional funds to provide adequate support to the QuIC for the establishment and maintenance of the menu of standardized measures, the design and pilot testing of reporting formats, the establishment and operation of the repository of pooled data, and the conduct of periodic evaluations of the impact of the new quality enhancement strategies. Lastly, some initial support for each of the government programs will also be needed so they can redesign their current oversight processes and establish the capacities required to receive and process the necessary clinical data and produce reports.

Fourth, the federal and state governments should immediately begin working in partnership with health care leaders, including representatives of consumer groups, the health professions, and health care organizations. It will be challenging to transform the current quality enhance-

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