Care transitions.

A set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care within the same location. Transitional care encompasses both the sending and the receiving of aspects of care (Coleman and Berenson, 2004).

Chronic conditions.

A condition that lasts a year or longer, limits what one can do, and may require ongoing care. Examples of chronic conditions are diabetes, cancer, glaucoma, and heart disease (Partnership for Solutions, 2001).

Clinicians.

Individual health care providers, such as physicians, nurse practitioners, nurses, physician assistants, and others.

Electronic health record.

A repository of electronically maintained information about an individual’s health care and corresponding clinical information management tools that provide alerts and reminders, linkages with external health knowledge sources, and tools for data analysis (Shortliffe et al., 2001).

Fee for service.

An approach to billing for health services in which providers charge a separate price or fee for each service provided or patient encounter. Under fee for service, the level of expenditures for health care depends on both the levels at which fees are set and the number of types of services provided.

Performance measures.

Includes both measures of patient perspectives on care, clinical quality, and patient outcomes.

• Measures of patient perspectives include patient assessment and satisfaction with their access to and interactions with the care delivery system (e.g., waiting times, information received from providers, choice of providers).

• Measures of clinical quality are specific quantitative indicators to identify whether the care provided conforms to established treatment goals and care processes for specific clinical presentations. Clinical quality measures generally consist of a descriptive statement or indicator (e.g., the rate of beta blocker usage after heart attack, the 30-day mortality rate following coronary artery bypass graft surgery), a list of data elements that are necessary to construct and/or report the measure, detailed specifications that direct how the data elements are to be collected (including the source of data), the population on whom the measure is constructed, the timing of data collection and reporting, the analytic models used to construct the measure, and the format in which the results will be presented. Measures may also include thresholds, standards, or other benchmarks of performance (IOM, 2002).

• Measures of patient outcomes include mortality, morbidity, and physical and mental functioning.

Providers.

Refers to both institutional providers of health care services (e.g., health plans, HMOs, hospitals, nursing homes) and clinicians (e.g., physicians, nurse practitioners, nurses, physician assistants).

Quality.

The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge (IOM, 1990).

Quality aims.

Descriptive elements of health care delivery goals, specifically:

1. Safe—avoiding injuries to patients from the care that is intended to help them.

2. Effective—providing services based on scientific knowledge to all who could benefit and refraining from providing services to those not likely to benefit (avoiding underuse and overuse, respectively).

3. Patient-centered—providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions.

4. Timely—reducing waits and sometimes harmful delays for both those who receive and those who give care.

5. Efficient—avoiding waste, including waste of equipment, supplies, ideas, or energy.

6. Equitable—providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and socioeconomic status (IOM, 2001).

Quality improvement.

A set of techniques for continuous study and improvement of the processes of delivering health care services and products to meet the needs and expectations of the customers of those services and products. It has three basic elements: customer knowledge, a focus on processes of health care delivery, and statistical approaches that aim to reduce variations in those processes (IOM, 1990).

Risk adjustment.

A process that modifies the analysis of performance measurement results by those elements of the patient population that affect results, are out of the control of providers, and are likely to be common and not randomly distributed.

Vulnerable populations.

Persons who are at increased risk of poor health outcomes. For example, persons with severe and chronic mental illness, the frail elderly, racial minorities, and the poor.

AAMC

Association of American Medical Colleges

ABIM

American Board of Internal Medicine

ACE

Angiotensin Converting Enzyme

ACGME

Accreditation Council for Graduate Medical Education

ACP

American College of Physicians

AHRQ

Agency for Healthcare Research and Quality

AIR

American Institutes for Research

AMA

American Medical Association

AQA

Ambulatory care Quality Alliance

ASIM

American Society of Internal Medicine

CABG

Coronary Artery Bypass Graft

CAHPS

Consumer Assessment of Healthcare Providers and Systems

CMS

Centers for Medicare and Medicaid Services

DHHS

Department of Health and Human Services

EHR

Electronic Health Record

ESRD

End-Stage Renal Disease

FAACT

Foundation for Accountability

GAO

Government Accountability Office

HCFA

Health Care Financing Administration

HEDIS

Health Plan Employer Data and Information Set

HMO

Health Maintenance Organization

HQA

Hospital Quality Alliance

IHI

Institute for Healthcare Improvement

IOM

Institute of Medicine

JAMA

Journal of the American Medical Association

JCAHO

Joint Commission on Accreditation of Healthcare Organizations

MDS

Minimum Data Set

MedPAC

Medicare Payment Advisory Commission

NCQA

National Committee for Quality Assurance

NHS

National Health Service

NQF

National Quality Forum

NSQIP

National Surgical Quality Improvement Program

OASIS

Outcome and Assessment Information Set

PCI

Percutaneous Coronary Intervention

PCPI

Physician’s Consortium for Performance Improvement

PPO

Preferred Provider Organization

QIO

Quality Improvement Organizations

SFB

Strategic Framework Board

Coleman EA, Berenson RA. 2004. Lost in transition: Challenges and opportunities for improving the quality of transitional care. Annals of Internal Medicine 141(7):533–536.

IOM (Institute of Medicine). 1990. Medicare: A Strategy for Quality Assurance. Volume 1. Washington, DC: National Academy Press.

IOM. 2001. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press.

IOM. 2002. Leadership by Example: Coordinating Government Roles in Improving Health Care Quality. Washington, DC: The National Academies Press.

Partnership for Solutions, A Project of Johns Hopkins University and The Robert Wood Johnson Foundation. 2001. The Problem: Chronic Conditions. [Online]. Available: http://www.partnershipforsolutions.com/problem/index.cfm [accessed November 14, 2005].

Shortliffe EH, Perreault LE, Wiederhold G, Fagan LM. 2001. Medical Informatics: Computer Applications in Healthcare and Biomedicine. New York: Springer-Verlag.