Plan Employer Data and Information Set) (Bradley et al., 2001; Lee, 2007). Beyond guidelines and measures, some health plans offered financial incentives under pay-for-performance contracts to increase the rates at which beta-blocker therapy was delivered (Lee, 2007). In addition to developing guidelines, the American College of Cardiology and American Heart Association both created programs to encourage clinicians to implement these guidelines in their practices. And the Institute for Healthcare Improvement included beta-blocker use as one component of its 100,000 Lives Campaign (Gosfield and Reinertsen, 2005). After this considerable amount of effort, on May 8, 2007, NCQA retired the use of a beta-blocker measure. The measure finally was no longer necessary because most patients under most health plans were now receiving this therapy for heart attack care (Lee, 2007).

Advances in science and technology have allowed health care to make great strides in treating diseases. Some diseases considered fatal just a generation ago are now routinely managed. Despite this progress, however, health care today displays notable shortcomings on each of the six aims for high-quality care identified in the Institute of Medicine (IOM) report Crossing the Quality Chasm: safety, effectiveness, efficiency, equity, timeliness, and patient-centeredness (2001). Care varies significantly from one part of the country to another and even from one town to another, with some areas offering high-quality, high-value care and others falling short of their potential. Substantial variations exist as well in the dissemination and adoption of new innovations. Some interventions and treatments with little evidence for superior outcomes spread rapidly, while others with a strong evidence base languish in obscurity. The shortfalls of the current health care system are captured by this simple fact: fully 160 years after Semmelweis discovered the importance of hand hygiene, many American health care institutions are finding it necessary to mount campaigns to encourage providers to wash their hands (Chassin and Loeb, 2011).

The health care environment itself places unnecessary burdens on health care professionals, siloing care activities, insufficiently meeting patient needs, and failing to disseminate knowledge broadly. The “system” has few elements that are systematic. Patients often report their frustration with a health care delivery enterprise that is fragmented, uncoordinated, and diffusely organized. As a result, they often are lost in the gaps and frustrated in trying to access the care they need.

Further, as discussed in Part I of this report, evidence on what is effective for a given patient under specific clinical circumstances often is lacking, poorly disseminated, or inconsistently implemented. The sheer volume of



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