Future Directions for the National Healthcare Quality and Disparities Reports (2010)

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Committee on Future Directions for the National Healthcare Quality and Disparities Reports Board on Health Care Services Cheryl Ulmer, Michelle Bruno, and Sheila Burke, Editors 

THE NATIONAL ACADEMIES PRESS  500 Fifth Street, N.W.  Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. This study was supported by Task No. #HHSP233200800005T between the National Academy of Sciences and the Agency for Healthcare Research and Quality. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the view of the organizations or agencies that provided support for this project. Library of Congress Cataloging-in-Publication Data Future directions for the national healthcare quality and disparities reports / Committee on Future Directions for the National Healthcare Quality and Disparities Reports, Board on Health Care Services ; Cheryl Ulmer, Michelle Bruno, and Sheila Burke, editors.    p. ; cm.   Includes bibliographical references.   ISBN 978-0-309-14985-3 (pbk.) — ISBN 978-0-309-14986-0 (pdf)   1. Medical care—United States. 2. Outcome assessment (Medical care)—United States. I. Ulmer, Cheryl. II. Bruno, Michelle. III. Burke, Sheila. IV. Institute of Medicine (U.S.). Committee on Future Directions for the National Healthcare Quality and Disparities Reports V. Institute of Medicine (U.S.). Board on Health Care Services.   [DNLM: 1. Health Services Research—methods—United States. 2. Health Services Research—trends—United States. 3. Forecasting—methods—United States. 4. Healthcare Disparities—trends—United States. 5. Outcome Assessment (Health Care)—trends—United States. 6. Quality of Health Care—trends—United States. W 84.3 F996 2010]   RA395.A3F865 2010   362.10973—dc22                    2010023053 Additional copies of this report are available from the National Academies Press, 500 Fifth Street, N.W., Lockbox 285, Wash- ington, DC 20055; (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area); Internet, http://www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu. Copyright 2010 by the National Academy of Sciences. All rights reserved. Printed in the United States of America The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin. Suggested citation: IOM (Institute of Medicine). 2010. Future Directions for the National Healthcare Quality and Disparities Reports. Washington, DC: The National Academies Press. 

“Knowing is not enough; we must apply. Willing is not enough; we must do.” —Goethe Advising the Nation. Improving Health. 

The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, shar- ing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and rec- ognizes the superior achievements of engineers. Dr. Charles M. Vest is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad com- munity of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the gov- ernment, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Charles M. Vest are chair and vice chair, respectively, of the National Research Council. www.national-academies.org 

COMMITTEE ON FUTURE DIRECTIONS FOR THE NATIONAL HEALTHCARE QUALITY AND DISPARITIES REPORTS SHEILA P. BURKE (Chair), Faculty Research Fellow, Malcolm Weiner Center for Social Policy, John F. Kennedy School of Government, Harvard University, Cambridge, MA IGNATIUS BAU, Program Director, The California Endowment, Oakland, CA ANNE C. BEAL, President, Aetna Foundation, Inc., Hartford, CT E. RICHARD BROWN, Professor, UCLA School of Public Health; Director, UCLA Center for Health Policy Research; Principal Investigator, California Health Interview Survey, Los Angeles, CA MARSHALL H. CHIN, Professor of Medicine, University of Chicago, Chicago, IL JOSÉ J. ESCARCE, Professor of Medicine, Division of General Internal Medicine and Health Services Research, UCLA School of Medicine, Los Angeles, CA KEVIN FISCELLA, Professor, Family Medicine and Community & Preventive Medicine, University of Rochester School of Medicine, University of Rochester, Rochester, NY ELLIOTT S. FISHER, Professor of Medicine and Community and Family Medicine, Dartmouth Medical School; Director, Center for Health Policy Research, Dartmouth Institute for Health Care Policy and Clinical Practice, Lebanon, NH DAWN M. FITZGERALD, Chief Executive Officer, QSource, Memphis, TN FOSTER GESTEN, Medical Director, Office of Health Insurance Programs, New York State Department of Health, Albany, NY BRENT C. JAMES, Chief Quality Officer and Executive Director, Institute for Health Care Delivery Research, Intermountain Health Care, Inc., Salt Lake City, UT JEFFREY KANG, Chief Medical Officer and Senior Vice President, Medical Strategy and Policy, CIGNA Corporation, Hartford, CT DAVID R. NERENZ, Director, Center for Health Services Research, Henry Ford Health System, Detroit, MI SHARON-LISE T. NORMAND, Professor, Department of Health Care Policy, Harvard Medical School; Professor, Department of Biostatistics, Harvard School of Public Health, Boston, MA CHRISTOPHER QUERAM, President and Chief Executive Officer, Wisconsin Collaborative for Healthcare Quality, Middleton, WI SARAH HUDSON SCHOLLE, Assistant Vice President for Research, National Committee for Quality Assurance, Washington, DC PAUL M. SCHYVE, Senior Vice President, The Joint Commission, Oakbrook Terrace, IL BRUCE SIEGEL, Director, Center for Health Care Quality, The George Washington University School of Public Health and Health Services, Washington, DC Study Staff CHERYL ULMER, Project Director MICHELLE BRUNO, Senior Program Associate (until February 2010) BERNADETTE McFADDEN, Research Associate CASSANDRA L. CACACE, Research Assistant ROGER C. HERDMAN, Board Director, Board on Health Care Services  Served through November 9, 2009.  



Reviewers This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report: DAVID CARLISLE, Office of Statewide Health Planning and Development, State of California, Sacramento, CA CARMEN R. GREEN, Department of Anesthesiology, University of Michigan, Ann Arbor, MI CARA V. JAMES, Kaiser Family Foundation, Washington, DC EDWARD KELLEY, World Health Organization, Geneva, Switzerland DUSHANKA V. KLEINMAN, Department of Epidemiology and Biostatistics, University of Maryland, College Park, MD JUDITH R. LAVE, Department of Health Policy & Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA ELIZABETH A. McGLYNN, The RAND Corporation, Santa Monica, CA THOMAS G. McGUIRE, Department of Health Care Policy, Harvard Medical School, Boston, MA LEE PARTRIDGE, National Partnership for Women and Families, Washington, DC RUTH T. PEROT, Summit Health Institute for Research and Education, Inc., Washington, DC PATRICK ROMANO, Center for Studying Health System Change, Washington, DC BARBARA RUDOLPH, Center for Health Systems Research and Analysis, University of Wisconsin, Madison; The Leapfrog Group, Madison, WI ELLEN WARTELLA, University of California, Riverside, Riverside, CA MILTON C. WEINSTEIN, Department of Health Policy and Management, Harvard School of Public Health, Boston, MA Although the reviewers listed above provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations nor did they see the final draft of the report before its release. vii 

viii REVIEWERS The review of this report was overseen by NEAL A. VANSELOW, IOM member, and CASWELL A. EVANS, JR., University of Illinois at Chicago. Appointed by the National Research Council and Institute of Medicine, they were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution. 

Foreword Ten years after the publication of the Institute of Medicine’s landmark Quality Chasm series of reports, we often do not know to what extent quality of care has improved. A range of studies and reports indicate that the quality of health care received in our nation is less than optimal, but we continue to lack sufficient information to determine how well new programs, changes in processes, and other interventions improve the quality and equity of care. The National Healthcare Quality and Disparities Reports play a fundamental role in examining quality improvement and disparities reduction. In this report, prepared at the request of the Agency for Healthcare Research and Quality, the Institute of Medicine suggests ways to reformulate and enhance our nation’s essential measures of quality and equity, to facilitate informed decision-making, and to help set the strategic direction of the nation’s quality improvement enterprise. I am grateful for the support of our sponsor and to the committee, ably led by Sheila Burke, which grabbled with complex issues involving the selection and prioritization of different measures, the needs of users, and advances in the field of quality measurement. Their work was reinforced by staff working under the direction of Cheryl Ulmer and including Michelle Bruno, Bernadette McFadden, and Cassandra Cacace. I commend both com- mittee and staff for this product and believe it provides a sound basis for strengthening the National Healthcare Quality and Disparities Reports. Harvey V. Fineberg, M.D., Ph.D. President, Institute of Medicine April 2010 ix 



Preface In 1998, the President’s Advisory Commission on Consumer Protection and Quality of Care in the Health Care Industry called for a national commitment to improving quality and reducing disparities at every level of the health care system. To reinforce this commitment, annual reports to Congress from the Agency for Healthcare Research and Quality (AHRQ) were initiated to document national trends, identify gaps in care, and paint a picture of the state of health care quality and disparities. These reports—the National Healthcare Quality Report (NHQR) and the National Healthcare Disparities Report (NHDR)—are consulted by health services researchers, state health officials, organizations implementing quality improvement and disparity elimination programs, advocates for specific health conditions or priority populations, and other stakeholders. Five years after the reports were first published, AHRQ turned to the Institute of Medicine (IOM) to evaluate the current NHQR and NHDR and to present a vision for their future content and presentation. Our IOM committee felt it essential to think about how the reports’ content and presentation could best foster action by various audiences to close health care quality gaps, particularly in measurement areas that represent the greatest opportunities for creating a high-quality, high-value, equitable health care system. It is through a lens of actionability and better matching of products to audience needs that the committee evaluated the current reports and made its recommendations. Embedded in the pages of this report are discussions of the ways to transform future iterations of the NHQR and NHDR. AHRQ could: • track national priorities for quality improvement and high impact measurement areas to inform collective action across federal and other public and private sector health care delivery programs; • conceptually and operationally link quality improvement and disparities elimination in the NHQR and NHDR; • highlight quality achievement by presenting best-in-class benchmarks; • move from only presenting historical trend data to also extrapolating rates of change to indicate when gaps might be closed at the existing pace; • present an assessment of the effect on population health of bridging quality and equity gaps; • analyze and present data in meaningful ways that identifies for Congress, states, and others the results of and prospects for evidence-based policies and interventions; and • support broader and sustained dissemination of report content. xi 

xii PREFACE We hope this report will be of help to AHRQ in promoting progress toward achieving optimal health care for the American people. As chair of this committee, I would like to thank my fellow committee members for giving their time and expertise so generously toward the completion of this report. Their spirited deliberations and contributions are greatly appreciated. On behalf of the committee, I would also like to thank the staff of the Board on Health Care Services who ably supported the committee in its endeavor. In particular, Cheryl Ulmer, study director, should be thanked for steering the committee throughout the process. Sheila Burke, Chair Committee on Future Directions for the National Healthcare Quality and Disparities Reports 

Acknowledgments The committee and staff are grateful to many individuals and organizations who contributed to this study. The committee would like to thank the Institute of Medicine Subcommittee on Standardized Collection of Race/Ethnic- ity Data for Healthcare Quality Improvement. The subcommittee members  were: MARGARITA ALEGRÍA, Director, Cambridge Health Alliance, Center for Multicultural Mental Health Research, Somerville, MA JOHN Z. AYANIAN, Professor of Medicine and Health Care Policy, Harvard Medical School, Boston, MA RODERICK J. HARRISON, Senior Research Scientist, Office of the Vice President for Research and Compliance, Howard University, Washington, DC ROMANA HASNAIN-WYNIA, Director, Center for Healthcare Equity; Associate Professor of Research, Northwestern University, Feinberg School of Medicine, Chicago, IL NINEZ PONCE, Associate Professor, Department of Health Services, UCLA School of Public Health, Los Angeles, CA WAYNE S. RAWLINS, National Medical Director, Aetna Government Health Plans, Aetna, Hartford, CT ALAN M. ZASLAVSKY, Professor of Statistics, Department of Health Care Policy, Harvard Medical School, Boston, MA Funding for this study was provided by the Agency for Healthcare Research and Quality (AHRQ). The com- mittee appreciates AHRQ’s support for this project and wishes to especially thank Carolyn Clancy, Ernest Moy, Jeff Brady, Farah Englert, Karen Ho, and Allan Lazar for sharing their expertise about the development and dis- semination of the NHQR and NHDR. In addition, the committee benefited from the testimony of the following individuals before the committee and subcommittee during public workshops: Karen Adams (National Quality Forum), Donald Berwick (Institute for Healthcare Improvement), Andrew Bindman (University of California, San Francisco, and CA Medicaid Research Institute), Kathryn L. Coltin (Harvard Pilgrim Health Care), Brenda Edwards (Division of Cancer Control & Population Sciences, National Cancer Institute), Marc Elliott (RAND Corporation), Irene Fraser (Agency for  Committee members Ignatius Bau, David Nerenz, and Paul Schyve were also members of the subcommittee. xiii 

xiv ACKNOWLEDGMENTS Healthcare Research and Quality), Allen Fremont (RAND Corporation), Ron Hays (Division of General Internal Medicine and Health Services Research, UCLA), Karen Humes (U.S. Census Bureau), Deeana Jang (Asian & Pacific Islander American Health Forum, speaking on behalf of Out of Many, One’s Health Data Taskforce), ­Marjorie Kagawa-Singer (UCLA School of Public Health), Karen Kmetik (American Medical Association and The Physician Consortium for Performance Improvement), David Lansky (Pacific Business Group on Health), Nicole Lurie (RAND Corporation, Center for Population Health and Health Disparities), Jennifer Madans (National Center for Health Statistics), Paul McGann (Office of Clinical Standards and Quality, Centers for Medicare and Medicaid Services), Marsha Regenstein (The George Washington University), Thomas Reilly (Office of Research, Development and Information, Centers for Medicare and Medicaid Services), Michael Rodriguez (Department of Family Medicine, David Geffen School of Medicine, UCLA), Patrick Romano (Divisions of General Medicine and General Pediatrics, Center for Healthcare Policy and Research, University of California, Davis), Joachim Roski (Engelberg Center for Health Care Reform, The Brookings Institution), Maribeth Shannon (Market and Policy Monitor Program, California HealthCare Foundation), Gayle Tang (National Diversity, Kaiser Permanente), Kalahn Taylor-Clark (Engelberg Center for Healthcare Reform, The Brookings Institution), Grace Ting (Health Equities Programs, Wellpoint, Inc.), Katherine K. Wallman (U.S. Office of Management and Budget), Thomas Williams (Integrated Healthcare Association), and Mara Youdelman (National Health Law Program). Others also provided valuable advice on the issues under study; these include Kirsten Anderson (Aetna), Douglas Boenning (U.S. Department of Health and Human Services), Arleen F. Brown (UCLA Division of General Internal Medicine), Helen Burstin (National Quality Forum), Pat Callaghan (Minnesota Department of Human Services), Eric Coleman (University of Colorado, Denver), Janet Corrigan (National Quality Forum), ­William Golden (Arkansas Medicaid, Department of Human Services), Sheldon Greenfield (University of California, Irvine), William E. Hammond (Duke University), W. David Helms (AcademyHealth), Catherine Hess (National Academy for State Health Policy), Bill Imada (IW Group, Inc.), George Isham (HealthPartners), Francine Jetton (Society of General Internal Medicine), Sherrie Kaplan (University of California, Irvine), Paul Kaye (Hudson River Health Care, Inc.), Alison Kirchgasser (Massachusetts Office of Medicine), Ann Kohler (National Association of State Medicaid Directors), Chris Lee (Kaiser Family Foundation), Lisa Lee (Kentucky Children’s Health Insurance Program), Dave Michalik (Delaware Division of Medicaid and Medical Assistance), Jeannette Noltenius (Out of Many, One), Nancy A. Rigotti (Massachusetts General Hospital), J. James Rohack (American Medical Associa- tion), Barbara Rudolph (The Leapfrog Group), Adam Schickedanz (University of California, San Francisco, and National Academy of Sciences Mirzayan Science and Technology Fellow through May 2009), Cathy Schoen (The Commonwealth Fund), Susan Schow (Maine Health Data Organization), Sora Park Tanjasiri (Center for Cancer Disparities Research), Caroline Taplin (U.S. Department of Health and Human Services), Alan Weil (National Academy for State Health Policy), and Judy Womack (Quality Oversight Bureau of TennCare). In addition, we would like to thank Suzanne Niemeyer and Chris Shreeve (Ketchum), Jeanette Chung and David Meltzer (University of Chicago), and Howard Wainer (National Board of Medical Examiners) who acted as consultants during the project and drafted additional materials for the report. Lastly, many individuals within the IOM were helpful throughout the study process including Clyde Behney, Patrick Burke, Rosemary Chalk, Janice Mehler, Abbey Meltzer, Christine Stencel, Vilija Teel, Jackie Turner, and Jordan Wyndelts. We would also like to thank Kerry Kemp for assisting in copyediting this report. 

Contents SUMMARY 1 1 INTRODUCTION 11 Study Charge and Approach, 11 National Reporting on the State of Quality and Disparities, 12 Key Issues Addressed by the Committee, 15 Limitations of the Study, 16 Organization of the Report, 16 References, 19 2 RE-ENVISIONING THE NHQR AND NHDR 21 Purpose and Audiences, 22 Calls for National Priority Areas, 26 The Committee’s Recommended Priority Areas, 28 Focusing Resources and Attention on National Priority Areas, 31 Summary, 36 References, 36 3 UPDATING THE FRAMEWORK FOR THE NHQR AND NHDR 39 The Original Framework for the NHQR and NHDR, 40 An Updated Framework for the NHQR and NHDR, 40 Rationale for the Dimensions of Equity and Value, 43 Rationale for the Four New Quality of Care Components, 46 Summary, 53 References, 53 4 ADOPTING A MORE QUANTITATIVE AND TRANSPARENT MEASURE SELECTION PROCESS 59 AHRQ’s Approach to Selecting Measures, 60 Improving Measure Selection, 63 xv 

xvi CONTENTS Principles and Criteria for Selection, 68 Quantitative Tools for Prioritizing Measures, 76 Summary, 85 References, 85 5 ENHANCING DATA RESOURCES 89 Building a National Data Infrastructure, 90 Filling Measurement and Data Needs, 91 Improving Race, Ethnicity, Language Need, Socioeconomic, and Insurance Status Data, 96 Summary, 105 References, 106 6 IMPROVING PRESENTATION OF INFORMATION 111 Matching Products to Audience Needs, 112 Telling a Story in the NHQR and NHDR, 120 Using Benchmarks to Show Achievement, 122 Refining the Presentation of Data, 126 Summary, 134 References, 134 7 IMPLEMENTING RECOMMENDED CHANGES 137 Resources Required to Implement Recommendations, 138 Evaluation of the AHRQ Report-Related Endeavor, 143 Timeline for Implementing Recommendations, 143 Conclusion, 145 References, 145 ACRONYMS 147 APPENDIXES A Previous IOM Recommendations for the National Healthcare Reports 151 B Key Findings of the NHQRs and NHDRs 155 C Previous Conceptual Framework 157 D Measurement Opportunities for the Framework’s Components of Quality Care 159 E HHS Interagency Workgroup for the NHQR and NHDR 171 F The Expected Population Value of Quality Indicator Reporting (EPV-QIR): A Framework for Prioritizing Healthcare Performance Measurement 175 G IOM Subcommittee on Standardized Collection of Race/Ethnicity Data for Healthcare Quality Improvement: Recommendations 207 H Additional Assessments of Data Presentation in the NHQR and NHDR 211 I An Illustrative Funding Example 217 J Committee Member and Staff Biographies 219 

Figures, Tables, and Boxes Summary Figure S-1 An updated conceptual framework for categorizing health care quality and disparities measurement, 4 Table S-1 Tailoring Products to Meet the Needs of Multiple Audiences, 8 Boxes S-1 The Committee’s Eight Recommended National Priority Areas for Health Care Quality Improvement, 3 S-2 Proposed Roles in Selecting Measures and Developing a Research Agenda, 5 Chapter 1 Figures 1-1 Overall reliability of the U.S. health system: Percentage of recommended care delivered, 14 1-2 Conceptual framework for a national quality measurement and reporting system, 15 Table 1-1 Issues Raised and Potential Solutions Related to the National Healthcare Reports and Their Related Products, 17 Box 1-1 Statement of Task for the IOM Committee on Future Directions for the National Healthcare Quality and Disparities Reports, 12 Chapter 2 Table 2-1 Overview of Priority Areas for Improving Health Care Identified by Leading Organizations, ­Initiatives, and Reports, 32 xvii 

xviii FIGURES, TABLES, AND BOXES Boxes 2-1 Objectives for AHRQ’s Reporting Effort in the NHQR, NHDR, and Related Products, 23 2-2 Definitions Used in This Report, 28 2-3 The Committee’s Eight Recommended National Priority Areas for Health Care Quality Improvement, 34 2-4 Health Care Quality Improvement: Illustrative Mechanisms of Influence and Actors, 36 Chapter 3 Figures 3-1 An updated conceptual framework for categorizing health care quality and disparities measurement, 42 3-2 Differences, disparities, and discrimination: Populations with equal access to health care, 45 Boxes 3-1 The Six Aims of Quality Care from the IOM’s Crossing the Quality Chasm Report, 41 3-2 Definitions of Equity and Value as Used in This Report, 44 Chapter 4 Figures 4-1 AHRQ, NAC, and subcommittee roles, 67 4-2 The Future Directions committee’s proposed decision-making process for selecting performance ­measures for the NHQR and NHDR and identifying measure and data needs, 70 4-3 Examples of how measures fitting two different priority areas might ultimately be ranked, 75 Tables 4-1 Ranking of Clinical Preventive Services for the U.S. Population, 80 4-2 Measures of Absolute and Relative Health Disparity, 83 Boxes 4-1 The IOM 2001 Recommendations for Measure Selection Criteria for the NHQR and NHDR, 61 4-2 AHRQ’s Current Criteria and Principles for Prioritizing Measures, 63 4-3 Healthy People 2020: An Explanation of the Prioritization Criteria Used for Sorting Healthy People Objectives, 76 Chapter 5 Figures 5-1 Recommended variables for standardized collection and reporting of race, ethnicity, and language need, 98 5-2 Both poor and wealthy New York City neighborhoods have high rates of new HIV diagnoses; overall, very low income Black New Yorkers have the highest rates of HIV diagnoses, 105 Tables 5-1 Data Sources Used in the 2008 NHQR and NHDR, 92 5-2 Examples of Subnational Datasets Not Currently Used in the NHDR and NHQR That May Provide Supporting Data, 96 Boxes 5-1 Using Subnational Data to Provide Insight into Potential Health Information Technology Measures, 95 5-2 Measuring Medical Home in Large, Population-Based Surveys, 95 

FIGURES, TABLES, AND BOXES xix Chapter 6 Figures 6-1 Oregon’s performance rate for pneumococcal vaccination sets a national benchmark for other states to strive to achieve, 124 6-2 Example of an alternate visual display, 130 6-3 Illustration of a gradient shading scheme, 131 Tables 6-1 Tailoring Products to Meet the Needs of Multiple Audiences, 113 6-2 Sections Recommended for Future National Healthcare Reports, 114 6-3 Definitions of Benchmarking from Various Sources, 122 Boxes 6-1 How Do I Find Disease-Specific Information in the NHDR?, 116 6-2 Key Elements of Telling a Story in the NHQR and NHDR, 121 6-3 A Suggested Approach to Improving Data Displays, 127 6-4 A Suggested Approach to Improving the Labeling of Graphic Data, 128 6-5 An Example of a Complex Data Display, 129 Chapter 7 Figure 7-1 Suggested timeline for implementing recommended activities, 144