whether their practices are improving. Reporting this type of information focuses attention on a specific quality issue and may support physicians and organizations in efforts to improve their practices (Porter, 2010). Other efforts, using voluntary reporting initiatives, sponsored by medical specialty societies or an integrated delivery system, have shown promise in providing information that clinicians can use for quality improvement activities (Ferguson et al., 2003; Grover et al., 2001).

A final means by which transparency may lead to improvement is by impacting a provider’s or health care organization’s reputation (Hibbard et al., 2005b). In a hospital reporting initiative in Wisconsin, hospitals indicated their belief that the report would affect their public reputation, although not patient volume (Hibbard et al., 2003). This concern appeared to motivate hospitals to undertake quality improvement initiatives.

Although reporting and transparency have had demonstrated impacts on clinical behavior, limited evidence exists about their overall impact on value. Studies and systematic reviews of the public reporting literature suggest that reporting of performance data stimulates quality improvement activities, especially at hospitals, but the impact on effectiveness, safety, and patient-centeredness remains unknown (Fung et al., 2008; Smith et al., 2012). Moreover, recent studies have shown limited effects of public reporting on the quality of care processes or health outcomes, such as mortality, suggesting that there are opportunities for improvement in designing and implementing transparency initiatives to produce optimal results (Ryan et al., 2012; Tu et al., 2009).

Improving transparency initiatives will require action on multiple fronts. First, there is a need to increase alignment among different transparency initiatives. Many reporting efforts are currently under way, each measuring different aspects of care delivery; this multiplicity can confuse consumers and limit impact (Rothberg et al., 2008). Second, there is concern that transparency initiatives may exacerbate health care disparities, as organizations and providers in geographic areas with limited resources may have less ability to undertake improvement efforts (Casalino et al., 2007). Finally, reporting requires that health care practices incur costs for establishing metrics in their data systems, for maintaining the data, and for entering data during each patient visit (Halladay et al., 2009). Although further work is needed to improve the practical implementation of transparency and minimize negative consequences, greater transparency is necessary to provide the information needed to promote continuous learning and improvement.

There also are specific issues to consider when transparency initiatives focus on cost, seeking to increase public knowledge and allow consumers to engage in cost-conscious shopping and thereby stimulate competition on cost and quality (Sinaiko and Rosenthal, 2011). The health care market

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