Prioritizing the Public in HHS Public Reporting Measures

Using and Improving Information on Quality, Cost, and Coverage to Support Health Care Improvement

Companion Report to the National Quality Strategy

December 2013

Department of Health & Human Services (HHS) Public Reporting of Quality and Efficiency Measures Workgroup

Contents

Introduction
Framework
HHS Public Reporting Accomplishments and Activities
Priorities for HHS Public Reporting
   Priority #1: Report on measures that are important to consumers and other key audiences in ways that can be easily understood and readily acted upon.
   Priority #2: Maximize the reach of information provided by HHS public reporting efforts.
   Priority #3: Enhance the effectiveness and efficiency of HHS public reporting efforts.
Next Steps

Introduction

The National Strategy for Quality Improvement in Health Care (hereafter referred to as the National Quality Strategy, or NQS) identifies public reporting as a key building block for achieving its three-part aim of better care, healthy people and communities, and affordable care. According to the NQS, “[p]ublic reporting initiatives offer consumers and payers vehicles to compare costs, review treatment outcomes, assess patient satisfaction, and hold providers accountable.” The NQS also recognizes that public reporting initiatives provide “important resources and motivation for clinicians and other providers to improve performance.”

The Department of Health & Human Services (HHS) Public Reporting of Quality and Efficiency Measures Workgroup (hereafter referred to as the Workgroup) was established to outline a set of Department-wide priorities for public reporting in support of the NQS three-part aim. The Workgroup identified three consensus-based priorities for making publicly reported data accessible and engaging to consumers and other stakeholders:

1. Report on measures that are relevant and important to consumers and other key audiences in ways that can be easily understood and readily acted upon;
2. Maximize the reach of information provided by HHS public reporting efforts; and
3. Enhance the effectiveness and efficiency of HHS public reporting efforts.

This companion report to the NQS aims to: 1) describe HHS priorities related to current and future public reporting initiatives in health care, health coverage, and population health across HHS; and 2) inform strategic planning, design, and research for individual HHS public reporting programs and for Department-wide public reporting initiatives.

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Framework

The Affordable Care Act (ACA) places unprecedented emphasis on reporting health care-related information to consumers and a wide variety of other audiences. Among its range of provisions on public reporting, the ACA requires public reporting on quality information on 1) inpatient rehabilitation facilities, 2) hospices, 3) cancer hospitals, 4) long-term care hospitals, 5) inpatient psychiatric facilities, 6) physicians, and 7) insurance options. The NQS, developed in response to the ACA, also reinforces the importance of public reporting for consumers and other audiences.

To recognize the use of public reporting as a major means for providing relevant information to both individual consumers and other audiences, the Workgroup determined that:

Public reporting comprises information sources and strategies to disseminate comparative information on health, health care providers and services, and health care coverage that allows target audiences to make informed decisions and drive improvements in health care quality, value, and coverage; in public health quality; and in population health.

This NQS companion report focuses on public reporting that facilitates comparative assessments of quality and efficiency in health care aimed at consumers while recognizing the importance of designing public reports for other audiences as well. This companion report calls attention to public reporting as an important strategy for fostering value-based health care and improving population health, and provides a foundation for the continued development of public reporting initiatives to support these goals.

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HHS Public Reporting Accomplishments and Activities

HHS has engaged in public reporting for many years at every level, from developing quality measures to supporting research about how to design public reports for consumers to operating public reporting Web sites that make performance information publicly available. This report highlights some of these accomplishments and activities, emphasizing consumer-oriented public reporting.

The Workgroup defined consumer-oriented public reporting as initiatives that allow consumers and other audiences to compare providers' (individual clinician, group, organization, facility/institution) quality, cost, efficiency, and other characteristics, as well as plan-level coverage, cost, quality, and other characteristics.¹ The HHS initiatives described in Table 1 were identified by examining the HHS Measure Inventory² for information on where each measure is currently reported and by consulting with HHS staff.

Table 1: HHS Consumer-Oriented Public Reporting Tools and Websites (as of May 2013)

In addition to these Web sites and tools, HHS has undertaken a range of public reporting activities in recent years. For example:

• In March 2011, the Agency for Healthcare Research and Quality (AHRQ) hosted a National Summit on Public Reporting for Consumers focused on reporting provider-specific performance measures for consumers.³
• A 2012 AHRQ-sponsored evidence report included input from a Technical Expert Panel and provided an overview of the impact of public reporting on patients, purchasers, and providers, as well as on the quality of health care.⁴
• AHRQ and the Centers for Medicare & Medicaid Services (CMS) support research grants to build the science of public reporting, targeting consumer-oriented public reports of health care quality and resource use.⁵

Public reports comparing the performance of individual health care providers, facilities, or delivery systems are most closely linked to the first and third NQS aims of better care and affordable care. Data and information about public health systems and population health such as vital statistics are most closely linked to the second NQS aim of healthy people and communities. The public reporting priorities outlined in this report align with other HHS initiatives targeting the aim of healthy people and communities. For example:

• The National Prevention Strategy. The National Prevention Council developed the National Prevention Strategy, under the direction of the ACA, and identified the promotion of empowered people within the health system as one of its key strategies. The National Prevention Council recognizes that “people are empowered when they have the knowledge, ability, resources, and motivation to identify and make healthy choices. When people are empowered, they are able to take an active role in improving their health, support their families and friends in making healthy choices, and lead community change.” To support this strategic direction, the National Prevention Strategy describes recommendations to provide people with tools and information to make healthy choices.⁶
• Healthy People 2020. The Healthy People initiative has established benchmarks for the health of all Americans for more than three decades, and includes attention to the importance of communicating information on population health.⁷
• Consensus Statement on Quality in Public Health. The Consensus Statement on Quality in the public health system represents an HHS-wide effort that defined nine aims as characteristics of public health quality. The purpose of the aims as stated in the Consensus Statement is to provide a systematic framework to ameliorate quality in public health practices across all sectors and to improve population health outcomes. Transparency—defined as data readily available to stakeholders including the public—is one of the nine aims for public health quality and is aligned with statements in the reporting document regarding public health data systems and also in promoting quality practices for healthy people and communities as stated in the NQS.⁸

Taken together, HHS public reporting initiatives represent one of the world's largest collections of comparative information on health care providers, facilities, and plans, featuring hundreds of measures and other information on approximately 850,000 individual health care professionals;⁹ 450 assisted reproductive technology clinics;¹⁰ 6,000 dialysis facilities;¹¹ 1,000 health centers;¹² 12,000 home health agencies;¹³ 5,000 hospitals;¹⁴ 16,000 nursing homes;¹⁵ and 4,000 plan benefit packages.¹⁶

HHS also provides easy electronic access to its Web sites through online portals such as HealthCare.gov and Medicare.gov, which provide users with a range of information, including lists of—and links to—some of the HHS consumer-oriented public reporting Web sites. For example, Medicare.gov hosts a suite of Compare Web sites such as Nursing Home Compare where users can find detailed information about the quality of nursing homes. The Nursing Home Compare Web site also makes available detailed survey findings on nursing homes to consumers and to researchers and reporters in downloadable form. The Medicare.gov Compare Web site data are also available in downloadable format on Data.Medicare.gov for use by a broader audience.

In addition to these Web sites, HHS supports HealthData.gov and Data.Medicare.gov, innovative Web sites that allow users to manipulate data used for public reporting and to download datasets. CMS also has revised data files on data.medicare.gov to make them much more useful to a broader audience.

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Priorities for HHS Public Reporting

The priorities developed by the Workgroup recognize the diversity of HHS public reporting initiatives, and serve as guide posts to improve the effectiveness of these initiatives, such as consideration of:

1. The information reported, the types of measures used, and the ways they are presented. Maximizing the effectiveness of public reporting requires the development and implementation of evidence-based best practices around the types of measures reported, the level of detail that various key audiences want, and how information should be displayed. Effective public reporting Web sites present actionable information about quality issues and other topics that matter to consumers and other users. Increasing the usability of measures for consumers includes expanded use of composite measures, which summarize information from multiple measures into a single measure. Examples of composite measures currently used in HHS public reporting include the Five Star Ratings used by Medicare Plan Finder to indicate overall quality in Medicare health plans, prescription drug plans, and Medigap policies, and the four Nursing Home Compare composite star ratings—an overall rating, health inspection rating, staffing rating, and quality measure rating. Composite measures make it easier to understand and compare health care and coverage options on quality and other important criteria. Additional details, including the results for the individual measures that make up a composite measure, can be available for consumers or other users interested in further information. A reporting framework to organize and present composite measures in dimensions that are meaningful and important—such as that currently used by Medicare Plan Finder and Nursing Home Compare—would further help audiences to process the information.
2. The ways in which HHS public reporting data are communicated. Although HHS public reporting Web sites are central resources, effective communication recognizes that information on the Web sites may also be disseminated in a variety of ways, including advertising by providers and plans, consumer sharing through social media, public reporting content shared by other Web sites, and partnerships with governmental and private for-profit and nonprofit organizations working to improve health and health care.
3. The ways that HHS Web sites are aligned. Thisincludes the need to align the Web sites as a collection that can reliably guide consumer decision making involving coverage and care across a range of settings.

Priority #1: Report on measures that are important to consumers and other key audiences in ways that can be easily understood and readily acted upon.

The growing number of people with health care coverage, coupled with the array and complexity of health issues, underscores the need for quality information about a diverse set of important concerns. However, HHS and its partners in quality measurement and reporting recognize that we do not have all the measures of health care quality, cost, and coverage that are needed. The NQS recognizes the need to address these “gaps” in available measures. To accomplish that, the focus is now on developing 1) measures of clinical outcomes, 2) patient-reported outcomes, 3) patient experience, 4) care coordination, 5) families of condition-related measures, and 6) information on consumer out-of-pocket costs.¹⁷

HHS has long been concerned with effective communication of health-related information to a range of people. Limited health literacy is common, and the implications are serious, with its relationship to poor health well established.¹⁸ A number of public reporting strategies can be used to improve usability of quality information.

Studies have found that “less is more” when presenting consumers with comparative information on health care quality. A wide array of measures provides consumers with information on a range of important issues and concern. However, the sheer number and complexity can also overwhelm them and undermine their ability to compare, decide, and take action.¹⁹ Consumers may only be able to process a limited number of variables when making a decision.^{20, 21} Composite or summary measures are one tool for reducing the cognitive burden for the user. ²²

Understandable formats, or meaningful displays of quality information, are essential to effective public reporting, and the ACA requires their use.²³ A systematic review of the evidence on formats concluded that public reporting should 1) provide an overall definition of quality, 2) define the elements of quality and use them as reporting categories, and 3) include information about the sponsor and methods.²⁴ To many consumers, health care quality is a concept they find unfamiliar and difficult to understand. For example, many consumers will interpret a quality measure showing a hospital with a comparatively low readmission rate to mean that it does not allow people to access the followup care they need, rather than as an indicator of inadequate care that within a short time leads to another hospital stay.²⁵ A reporting framework, which uses a limited number of simple and straightforward categories grounded in what consumers commonly understand about quality, can provide guidance.²⁶ Users may choose to “drill down” to additional information in the areas that are most important to them.²⁷

The NQS calls for reporting to consumers on the price of care and coverage, in addition to quality. Consumers may need information on comparative out-of-pocket costs in addition to more general information on prices or premiums.^{28, 29} If cost and quality information can be linked, consumers can use this information to choose the highest value plan or provider.^{30, 31}

Public reporting Web sites can also drive improvement by giving health care plans and providers information about their performance compared to their peers.³² For example, physician groups that participated in the Wisconsin Collaborative for Healthcare Quality from 2004 to 2009 improved performance on many publicly reported measures during that time^.33

Additional research is needed to better understand how to make a range of information more actionable by audiences other than consumers. For example, HHS public reporting Web sites are often used by those who assist consumers with making decisions on health care or coverage. For instance, health care professionals help patients to choose a hospital and information intermediaries help consumers to select health insurance plans. In addition, employers may be interested in comparative population health and public health system information when deciding where to locate a business or a new office, but more evidence is needed for effectively communicating population health information in ways that support these and other uses. Along the same lines, the National Prevention Strategy recommends providing people with the tools and information to make healthy choices; the Federal Government has committed to supporting research and programs that help people make healthy choices, for example, to understand how options should be presented.

A wide range of ongoing HHS activities are addressing the above priority of reporting on important measures in ways that can be easily understood and readily acted upon. For example:

• Nursing Home Compare and Medicare Plan Finder post overall ratings of quality, as well as summary scores in a number of domains.
• Through a contract with the National Quality Forum (NQF), a consensus-based entity that reviews, endorses, and recommends use of standardized health care performance measures, HHS supported a consensus project to reassess NQF's existing guidance for evaluating composite measures.³⁴ The revised guidance will improve the development of composite measures and will make the composite measure endorsement process more understandable and effective.
• Multiple agencies are discussing the need for an approach to reporting population health measures, including developing and using measures for payment initiatives with a population health component such as accountable care organization (ACO) models.
• CMS recently redesigned its Compare Web sites to standardize the Web sites' look and feel.³⁵
• The Centers for Disease Control and Prevention (CDC), the Health Resources and Services Administration (HRSA), and other public and private stakeholders are supporting an Institute of Medicine Roundtable on Population Health Improvement to explore factors beyond medical care that influence health.³⁶ The Roundtable's work will include a discussion of how to measure population health and how to use the measures of population health.
• The Office of the National Coordinator for Health Information Technology (ONC), CMS, the Office of the Assistant Secretary for Planning and Evaluation (ASPE), and others are discussing opportunities for incorporating consumer interests and perspectives into the measure development process as a way to produce more consumer-friendly quality measures.

Priority #2: Maximize the reach of information provided by HHS public reporting efforts.

For consumers and other key audiences to act on information about health care, coverage, and population health, they must first know about it. HHS Web sites are the central vehicles to disseminate public reporting information.

Consumers and other audiences will continue to need the kind of accessible information that HHS public reporting Web sites supply. While some Web sites with health care information charge fees, government Web sites are free for users. In addition, HHS public reporting Web sites are transparent, providing technical information and access to the data that informs their reports. Transparency has been cited as a major element of satisfaction and overall trust in government in many user surveys of government Web sites.³⁷

Agencies should continue to improve and update these Web sites. It is important for public reporting Web sites to communicate information by attracting growing numbers of visitors and providing a satisfying user experience so that visitors return. It is also important to apply best practices for effective Web design and communication, such as those presented on the Federal Web site HowTo.gov.³⁸

Agencies are seeking to enhance user experience in a variety of ways. Formative research is conducted not only to create new Web sites, such as the Health Insurance Marketplace, but also to develop new approaches to existing Web sites. Existing Web sites must remain current to reflect the ever-changing nature of health care and coverage, and this will require ongoing user testing and consumer research. To continue to be effective, they must also take advantage of new developments in technology and the science of public reporting. For example, CMS conducted formative research to guide the response of the Compare Web sites to new public reporting requirements under the ACA. It also conducted research to guide its response to the Digital Government Strategy, released in 2012 by the Obama Administration, which created new technical expectations for executive departments and agencies in delivering digital services and providing digital resources.³⁹

HHS also seeks to ensure that information is accessible through any device, including computer, mobile phone, or tablet. The design of a public reporting Web site or other initiative should be crafted to facilitate the tasks that users want to accomplish, with the devices and in the settings they prefer. In addition, public reporting Web sites should use feedback from users to help identify what information is missing and what is most helpful.

Although the predominant approach to public reporting holds that people learn about HHS public reporting information by visiting Web sites, consumers need not visit the Web sites to learn about—and act on—public reporting.⁴⁰ Concise, consumer-friendly content such as star ratings can be widely spread through advertising and other channels by plans and providers,⁴¹ with agency guidance helping to ensure accurate use.⁴² Public reporting can also be spread through social media. Consumers increasingly use social networks to share information on health. Sharing information on health care has been identified as a logical next step.⁴³ Agencies are actively exploring how best to promote public reporting using social media.

The following are examples of how HHS is seeking to maximize the reach of public reporting:

• In an effort to improve public reporting and provide consumers with transparent, timely information they can trust, AHRQ and CMS are supporting 17 research studies on the content, design, dissemination, and underlying data and methodology of public reports.⁴⁴
• CMS provides an array of resources for software developers. CMS publishes the most current Compare Web site data sets on Data.Medicare.Gov using Socrata, an open data platform.⁴⁵ Data.Medicare.Gov functionalities allow developers to access data through an application programming interface to create applications that display and use the data in new and exciting ways. Socrata also allows users to interact with the data, subscribe to a dataset's RSS feed, and share it on Facebook or Twitter.
• The CMS Compare Web sites use responsive Web design, which makes information easily viewed on mobile, desktop, and other devices.
• The HHS Health Data Initiative, begun in 2010 by the Institute of Medicine (IOM) and HHS, makes public reporting and other health datasets widely available, supports their dissemination on a variety of partner Web sites, and spurs the creation of new applications and services. Each year, the initiative holds a forum for data users, data owners, developers, and stakeholders from venture capital, government and business to meet and explore a range of data-related issues.

Priority #3: Enhance the effectiveness and efficiency of HHS public reporting efforts.

Consumers should experience HHS public reporting as a distinctive collection of authoritative and easy-to-use Web sites that can reliably guide them across a series of critical decisions that can involve multiple care settings or coverage and care issues. This will require alignment across a number of dimensions, including the organization of Web sites, the presentation of information, and the navigational features that are available. Alignment will not only make it easier for users to move from one Web site to the other, it will also result in efficiencies of development and production as the sites become more standardized. Program and Web site alignment across HHS will also facilitate efforts to align with other Federal agencies, states, and the private sector. Coordination with a unified public reporting initiative is more feasible, and the potential impact of partnerships and collaboration is far greater. Alignment is a challenging task, requiring the development of strategic plans to identify the most effective ways and realistic timelines for ensuring that it succeeds.

In addition to aligning HHS public reporting efforts, it is important to ensure the framework and guidance provided here aligns with the NQS broadly as well as with corresponding principles and recommendations of the National Prevention Strategy, the HHS Strategic Plan, the National Action Plan to Improve Health Literacy, and other Department-wide guidance.

Ongoing work across HHS is making strides toward enhancing the effectiveness and efficiency of HHS public reporting efforts. For example:

• The HHS Public Reporting of Quality and Efficiency Measures Workgroup built consensus on the priorities described in this NQS companion report. Going forward, this Workgroup will share information about agencies' public reporting work and track progress toward these priorities.
• The Digital Government Strategy emphasizes the need for a shared platform approach and a customer-centric approach, in turn shaping the development of new public reporting initiatives and updates to current Web sites.
• Driven by the need to align measures in use across the Department and to address other related measurement policy issues, AHRQ and CMS convened the HHS Measurement Policy Council, an interagency workgroup with representatives from across HHS. The Measurement Policy Council is building consensus about core sets of measures that all HHS agencies should use when measuring the same topic area and is providing ongoing guidance about aligning measure development. This effort includes measures used for clinical care, public health, and population health purposes.
• CMS is exploring options for better integration of the Compare Web sites, such as enabling users to search more easily for information across the continuum of care.

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Next Steps

The priorities described in this NQS companion report can guide HHS agencies' work in the area of public reporting, and will inform the development of annual agency-specific quality strategic plans. These priorities also provide a framework for agencies to describe ongoing public reporting initiatives and identify opportunities to commit to new activities.

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References

¹ This definition is adapted from AHRQ's Closing the Quality Gap: Revisiting the State of the Science (Vol. 5: Public Reporting as a Quality Improvement Strategy). Available at https://www.ahrq.gov/research/findings/evidence-based-reports/gapqistp.html.
² The HHS Measures Inventory is available at http://www.qualitymeasures.ahrq.gov/hhs/index.aspx.
³ A subset of papers presented at the conference can be found in the March 2012 issue of Health Affairs.
⁴ Totten, A., et al. Public Reporting as a Quality Improvement Strategy. Closing the Quality Gap: Revisiting the State of the Science. 2012. Available at https://www.ahrq.gov/research/findings/evidence-based-reports/gapqistp.html.
⁵ AHRQ. Building the Science of Public Reporting: Research Grants. 2012. Available at https://www.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools/sciencepubreport/index.html
⁶ National Prevention Council. National Prevention Strategy: Empowered People. 2011. Available at http://www.surgeongeneral.gov/initiatives/prevention/strategy/empowered-people.pdf.
⁷ Information about the Healthy People 2020 initiative can be found at http://www.healthypeople.gov/2020/default.aspx.
⁸ U.S. Department of Health and Human Services. Consensus Statement on Quality in the Public Health System. 2008. Available at http://www.hhs.gov/ash/initiatives/quality/quality/phqf-consensus-statement.html.
⁹ Estimate from e-mail correspondence with CMS.
¹⁰ Centers for Disease Control and Prevention. Assisted Reproductive Technology Report. 2013. Available at http://www.cdc.gov/art/.
¹¹ Estimate from Dialysis Facility Compare download database, available at http://www.medicare.gov/download/downloaddb.asp.
¹² Estimate from 2011 Individual Health Center Data, retrieved from http://bphc.hrsa.gov/uds/view.aspx?q=rlg.
¹³ Estimate from Home Health Compare downloadable database, available at http://www.medicare.gov/download/downloaddb.asp.
¹⁴ Estimate from Hospital Compare downloadable database, available at http://www.medicare.gov/download/downloaddb.asp.
¹⁵ Estimate from Nursing Home Compare downloadable database, available at https://data.medicare.gov/data/nursing-home-compare.
¹⁶ Estimate from Medicare Plan Ratings downloadable database, available at http://www.medicare.gov/download/downloaddb.asp.
¹⁷ HHS. National Strategy for Quality Improvement in Health Care: 2012 Annual Report to Congress. 2012. Available at https://www.ahrq.gov/workingforquality/nqs/nqs2012annlrpt.pdf.
¹⁸ HHS Office of Disease Prevention and Health Promotion. National Action Plan to Improve Health Literacy. 2013. Available at http://www.health.gov/communication/HLActionPlan/pdf/Health_Literacy_Action_Plan.pdf. ¹⁹ Vaiana, M., and E. McGlynn, What Cognitive Science Tells Us about the Design of Reports for Consumers. 2002. Medical Care Research and Review 59:3–35.
²⁰ Peters, E., et al. Less Is More in Presenting Quality Information to Consumers. 2008. Medical Care Research and Review 64(2):169–190.
²¹ Hibbard, J., and E. Peters. Supporting Informed Consumer Health Care Decisions: Data Presentation Approaches that Facilitate the Use of Information in Choice. 2003. Annual Review of Public Health 24:413–33.
²² Hibbard, J., and S. Sofaer. Best Practices in Public Reporting No. 1: How to Effectively Present Health Care Performance Data to Consumers. 2010. Available at https://www.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools/pubrptguide1/pubrptguide1.pdf.
²³ For example, see Section 3001.
²⁴ Totten, A., et al. Public Presentation of Health System or Facility Data about Quality and Safety: A Systematic Review. 2012. Available at http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0033326/.
²⁵ For example, see Hibbard and Sofaer 2010.
²⁶ For example, see Hibbard and Sofaer 2010.
²⁷ Robert Wood Johnson Foundation. How to Display Comparative Information that People Can Understand and Use. 2010. Available at http://forces4quality.org/how-display-comparative-information-people-can-understand-and-use/.
²⁸ For example, see Hibbard and Sofaer 2010.
²⁹ Painter, M., and M. Chernew. Counting Change: Measuring Health Care Prices, Costs, and Spending. 2012. Available at http://www.rwjf.org/content/dam/web-assets/2012/03/counting-change.
³⁰ Hibbard, J., et al. An Experiment Shows That a Well-Designed Report On Costs And Quality Can Help Consumers Choose High-Value Health Care. 2012. Health Affairs 31(3):560–568.
³¹ Lenz, J., et al. Value Judgment: Helping Health Care Consumers Use Quality and Cost Information. 2012. Available at http://www.chcf.org/~/media/MEDIA%20LIBRARY%20Files/PDF/V/PDF%20ValueJudgment
QualityCostInformation.pdf.
³² See Totten et al. 2012 as noted in (2) above.
³³ Lamb, G., et al. Publicly Reported Quality-of-Care Measures Influenced Wisconsin Physician Groups to Improve Performance. 2013. Health Affairs 32(3):536–543.
³⁴ National Quality Forum. Composite Measure Evaluation Guidance. 2013. Available at http://www.qualityforum.org/Projects/c-d/Composite_Evaluation_Guidance_Reassessment/Composite_Measure_Evaluation_Guidance.aspx.
³⁵ Goodrich, K., et al. E. Garcia, and P. Conway. A History of and a Vision for CMS Quality Measurement Programs. The Joint Commission Journal on Quality and Patient Safety 38(10):465–470.
³⁶ Institute of Medicine. Roundtable on Population Health Improvement. 2013. Available at http://www.iom.edu/Activities/PublicHealth/PopulationHealthImprovementRT.aspx.
³⁷ ForeSee results e-government transparency index (2010 year in review). Available at http://www.foreseeresults.com/research-white-papers/_downloads/e-gov-transparency-index-2010-year-in-review-foresee.pdf.
³⁸ See http://www.howto.gov.
³⁹ Executive Office of the President. 2012. Digital Government: Building a 21st Century Platform to Better Serve the American People. Available at http://www.whitehouse.gov/sites/default/files/omb/egov/digital-government/digital-government.html.
⁴⁰ Reid, R., et al. Association Between Medicare Star Ratings and Enrollment. 2013. JAMA 309(3):267–274.
⁴¹ Weaver, C. Medicare Plans See Dollars in the Stars. Kaiser Health News, Oct. 11, 2011. Available at http://www.kaiserhealthnews.org/Stories/2011/October/11/Medicare-Advantage-Star-Ratings.aspx.
⁴² Medicare Marketing Guidelines. 2013. Available at http://www.cms.gov/Medicare/Health-Plans/ManagedCareMarketing/FinalPartCMarketingGuidelines.html
⁴³ Fox, S. The Social Life of Health Information. 2011. Available at http://pewinternet.org/Reports/2011/Social-Life-of-Health-Info.aspx.
⁴⁴ Medicare Marketing Guidelines. 2013. Available at http://www.cms.gov/Medicare/Health-Plans/ManagedCareMarketing/FinalPartCMarketingGuidelines.html
⁴⁵ For information on Socrata, see http://www.socrata.com/customer-spotlight/medicare/.

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