measures), the data generated to calculate measures should be byproducts of the patient care process and should reside within an electronic health record system. For example, the data required to calculate standardized measures for assessing the quality of patient care provided to diabetics (e.g., cholesterol and hemoglobin A1c levels) should be captured as a part of patient care encounters. This approach has several advantages: (1) it allows for the development of computerized decision-support systems (e.g., prompts to providers and patients that the patient is due for an annual retinal exam); (2) it enables more immediate calculation of measures and feedback to providers on performance; and (3) it minimizes the burden associated with special data collection processes. These data reflect the health care delivery system; in and of themselves they do not adequately address population and public health.

Principle 6: A Central Role for the Patient’s Voice

The performance measurement system should also include direct reports and ratings from patients and family caregivers. Patients need a voice in the process of selecting measures and designing public reports. The input of patients and family caregivers should reflect their viewpoints on the quality and functionality of the care received. Caregivers’ perceptions of the quality of care provided should also be incorporated into the measurement system.

Principle 7: Individual-, Population-, and Systems-Based Measurement

Measurement and measures should assess the health and health care of both individuals and populations and the many systems within which care is provided. A national system for performance measurement and reporting should include both measures of the quality of care provided by the personal health care system and measures of population health, health behaviors, and unmet health needs. The measure set should include measures of access and unmet service needs for the entire population of a community and for specific groups most likely to experience access limitations because of an inability to pay; high levels of uninsurance or underinsurance; racial, ethnic, class, cultural, and linguistic barriers; or geographic impediments. The measure set should also include measures of the efficiency of the local health system, such as resource use compared with that of other communities.

Principle 8: Shared Accountability

Measurement should not be constrained by the absence of a current, identifiable, single responsible agent. A national system should measure pro-



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