Table 1. Proposed Maryland Digital Measurement Progression Plan and Data Assessment for Four Selected Population Health Measures Over Time and at Various Geographic Levels*.

Measurement Type Based on Available Data →	Process and Output						Outcome/ Impact
Time Frame for Collecting Proposed Measures →	Short Term (Current)			Near Term (2 years)			Mid to Long Term (3 to 5 years)		Longer Term (8 to 10 years)
Available Geographic Level over Time (Based on Available Data Source) →	Zip code/ Track	County	State	Individual		Zip code/ Track
Available Data Sources over Time →	HSCRC	BRFSS**	Medicaid	EHR (documented measures by providers)	CRISP (transmitted and stored data from providers to CRISP)	MCDB
Measurement Domains ↓ and Change in Measurement Domains Over Time →							SHIP Categories
BMI screening and follow-up for community/ population (NQF measure # 0421 and CMS measure # 69)		BMI score based on self-reported weight and height of a representative sample (12,369 people) for the state of Maryland		BMI score based on measured height and weight by providers in the clinic	BMI score based on data found in a C-CDA. Intervention and procedure orders within a C-CDA are not available, which is necessary to calculate follow-up visits		Healthy Living	Adults who are a healthy weight	Obesity surveillance in a specific catchment area using EHR data
								Children and adolescents who are obese
Screening for high BP and follow-up for community/population (CMS measure # 22v5)				Screening for high BP and follow-up for a community/population (with specific BP)	BP measure based on data found in C-CDA. There is partial coverage for data needed to calculate follow-up visits	Claims data on screening for high BP and follow-up visit	Quality Preventive Care	Emergency department visit rate due to hypertension	BP surveillance in a specific catchment area with application of BP measurements through EHR
Current adult smoking within population		Based on the BRFSS questionnaire asking current smoking habits among adults of a representative sample (12,369 people) for the state of Maryland	Claims data on smoking medical assistance	Individual data on smoking/tobacco use cessation, and medical assistance	Most data elements needed to calculate smoking cessation will be found in a C-CDA	Claims data on smoking medical assistance	Healthy Living	Adults who currently smoke	Application of smoking status measurement through EHR for surveillance of smoking trends in a specific catchment area
Falls; Fall-related injury rate	Number of falls resulted in an ED visit or hospitalization in a zip code including physician services categorized as an outpatient data or emergency room visit	History of falls; a representative sample (12,369 people) for the state of Maryland	Claims data on falls related ED visit and hospitalization	Individual data on falls related visit in ED or inpatient	Data on falls related visit in ED or inpatient	Claims data on ED visit and hospitalization	Healthy Communities	Fall-related death rate	Falls surveillance including repeated falls among individuals in a specific catchment area using EHR data

* Note that the full measurement plan also includes cost and patient experience measures.

** Currently in-use data. Other data sources are available in different time frames which potentially could provide population health assessment.

BMI: Body Mass Index, BP: Blood Pressure, BRFSS: Behavioral Risk Factor Surveillance System, C-CDA: Consolidated-Clinical Document Architecture, CMS: Center for Medicare and Medicaid Services, CRISP: Chesapeake Regional Information System for our Patients, ED: Emergency Department, EHR: Electronic Health Record, HSCRC: Health Services Cost Review Commission, MCDB: Maryland Medical Care Data Base, NQF: National Quality Forum, SHIP: State Health Improvement Process.