The American healthcare system is complex, fragmented and currently the most expensive in the world. High-quality care has traditionally not been emphasized, which seems to be partly due to the payment system which is predominantly fee-for-service with the absence of a single payer. The country does not have a central agency responsible for ensuring the quality of the healthcare services delivered to patients, although the Department of Health and Human Services (HHS) is the principal federal ministry. The Center for Medicare and Medicaid Services (CMS), an agency under HHS, is the largest payer of healthcare ser­vices in the country and has significant influence on how the quality of care is measured and evaluated and what is paid for, even in the private sector.

The ongoing healthcare reform is still politically controversial, but includes many initia­tives with the objective of making healthcare more cost-efficient and of higher quality than before. It is believed that paying for quality will lower costs as well. There is more interest in patient-centered care now than before and a more holistic view of care is emerging.

Many different types of quality measures are collected by a variety of stakeholders, such as measure developers, entities involved in endorsement, certification, or accreditation, fed­eral agencies, and a wide range of measure end-users, including health plans, hospital and medical systems, and other providers of health services, local and state agencies, and multi-stakeholder alliances. This is problematic and can be a big burden for the providers, because it has resulted in multiple reporting requirements since health plans have not de­veloped similar approaches to quality reporting.

CMS runs several programs wherein healthcare providers are reimbursed for reporting quality measures as well as delivering care that meets certain quality standards. There is an ongoing shift when paying for healthcare services, from paying for volume (fee-for-service), to paying for results (pay-for-performance), both in the public and private insur­ance sector.

There are numerous registries in the country with many different owners, such as profes­sional organizations, insurance companies, healthcare providers, researchers, and others, but relatively few initiatives that span the entire country. There is currently no list of all registries in the United States, although a new project by the Agency for Healthcare Research and Quality (AHRQ) is trying to change this. There is an emerging interest in using disease registries to monitor and improve healthcare quality and political initiatives on mandating participation in registries exist. CMS has several such requirements in place when paying for care.

The federal government has invested a considerable amount of money into the implemen­tation of Electronic Health Records (EHR) in the healthcare system. Incentives are paid to eligible hospitals and professionals that adopt, implement, upgrade or demonstrate “meaningful use” of certified EHRs. Submission of data to a clinical data registry will be one of the criteria that eligible professionals and hospitals must meet in order to continue to participate in EHR incentive programs in the future.

Three examples of healthcare providers that deliver high-quality care are presented in this report: the Veterans Health Administration, Kaiser Permanente and Intermountain Healthcare. They were chosen on the basis that they all rely heavily on quality measure­ments and use EHRs and registries in their work.