This document proposes the creation of a Federal Performance Architecture (FPA) to help coordinate and guide the numerous changes to the US healthcare system proposed in the Affordable Care Act. The FPA would apply interdisciplinary scientific methods and draw on data from emerging health IT infrastructures to provide evidence on standards of care, prevention strategies, and patient-centered informatics. This evidence could then help ensure improvements in healthcare quality, access, and costs. The FPA would analyze initiatives' effects on outcomes, access, and costs. It would also provide population-based evidence and demographic analyses to better tailor services and policies. Establishing such a coordinating framework could sustainably benefit research, policies, and health systems both nationally and globally

1. Health Outcome Infrastructure - Paschane © 2010 Page 1
Health Outcome Infrastructure Initiative
David M. Paschane, Ph.D.
The Emerging Research Paradigm in Health IT
The paucity of coherent healthcare infrastructure may be the most significant risk to health,
globally, and the reason for pursuing an Internet-based alternative. Rich and poor countries
alike are demonstrating an enthusiasm for health IT solutions because it promises a leap
forward in the long-standing delays in infrastructural development. The pursuit of Internet-
enabled health IT may produce surprising results, such as rapidly matured healthcare
infrastructure in middle-tier economies, where they face fewer of the entrenched institutional
problems that hold back the high-tier economies. Nevertheless, these sudden changes come
with risk—unwanted consequences in how the organization of medical services and patient
information affects knowledge, control, and opportunities in the operations and experiences of
healthcare. The purpose of the Health Outcome Infrastructure Initiative is to apply
interdisciplinary sciences to representative examples of emerging IT-enabled healthcare
infrastructure in various economic contexts, and use these maturing models to inspire
commercial and government investors to expand and stabilize the healthcare infrastructures,
domestically and abroad.
The Initiative has three complementary foci in researching emerging healthcare infrastructure
and health IT. Each is strengthened through contextualized, continuous, recursive analyses
applied to population segmentations:
1. Population-based, clinical modeling of care standards across conditions of management
2. Patient agency as a nexus of personalized education and psychology of self-care
3. Organizational performance as sustainable and systemic improvements in outcomes
The three foci preserve a balance in healthcare infrastructure—evidence of the interactions
between providers, patients, and institutions—with an emphasis on continuous, applied
knowledge, especially as it is interpreted by different people in different contexts. The
framework for all analyses is the continuum of disease risk, a robust scope of detail than is
absent in the prevention versus treatment dichotomy.
Infrastructure as Federal Performance Architecture
A health outcome infrastructure is going to facilitate the macro view of causality in a complex
system, and each node in the “workflow” is a major decision domain. Throughout, the

2. Health Outcome Infrastructure Initiative – Paschane 2010© Page 2
infrastructure requires evidence of how the whole is affecting the disparate actions impacting
behaviors downstream, and ultimately the outcomes in health and economics.
The following Federal Performance Architecture (FPA) is a proposed set of models and
continuous analyses that enable a sustainable management of the causes of outcomes.
The Patient Protection and Affordable Care Act (P.L. 111-148) and Health Care and Education
Reconciliation Act (P.L. 111-152) propose many changes to the National health system that can
increase access, improve quality, and decrease costs. Throughout the Acts there are
suggestions that the new system will be evidence-based, IT-centric, and effective at
coordinating best practice services, from preventing ill health to managing chronic conditions.
However, the Acts do not specify an FPA to organize and integrate the interdisciplinary research
that enables desired outcomes.
The following list is 36 outcome goals in the Patient Protection and Affordable Care Act that
have major knowledge dependencies and will require an effective FPA to support the
coordination and routine use of evidence in guiding outcomes.
Section Summary Outcome Goal Major Knowledge Dependency Category
1102 Cover Employers’ Retirees Evidence-based standards for chronic and promotion care
1103 Consumer-Selected Plans Evidence-based designs for patient-tailored informatics
2406 Effective Long-Term Care Evidence-based standards for chronic and promotion care
Core Healthcare Cost Analyses
Core Healthcare Quality Analyses
Analyses:
Patient / Provider Use
of Self-Care Tools
and Training
Model:
Patient / Family Self-
Care Role in Care
Management
Model:
Population-Based
Standards of Clinical
Care
Analyses:
Provider Use of
Standards of Care
Analyses:
Mutual Satisfaction in
Active Treatment and
Self-Care
Analyses:
Clinical Decisions by
Pay Structure
Model:
Cost Offsets in Use of
Lower Priced Services
and Methods
Analyses:
Patient / Provider
Decisions on Visits
and Tests
Analyses:
Patient Use of Points
of Care by Price
Analyses:
Patient Use of
Methods by
Frequency and Costs
Model:
Cost Offsets in Timely
Detection and
Coordinated Care
Analyses:
Patient Use of Care
by Frequency and
Costs
Analyses:
Differences in Costs
Attributed to Initiatives
Decrease
Costs
Analyses:
Differences in Quality
Attributed to Initiatives
Increase
Quality
Increase Health
Centers or Rural Doctor
Access
Model:
Energy & IT
Efficiencies
Analyses:
Facility Operations
and Construction
Model:
National View of
Cohort Needs and
Service Contexts
Analyses:
Engagements by
Service and Provider
Types by Places
Increase
Access
Model:
Complementary Care
and Care Seeking
Increase Health
Insurance Coverage
(Subsidy or Direct)
Model:
Growth of Intelligent
Infrastructure for
Service & Analysis
Increase Health Care
Analytic Standards and
Evaluation
Increase Health IT in
Records, Navigation,
and Management
Analyses:
Value of Data from
Infrastructure SourcesAnalyses:
Maturity of
Performance
Architecture
Model:
Development of IT
Interface / Analytic
Layer
Analyses:
Control of Design and
Deployment of IT
Components
Model:
Organizational
Performance
Architecture
Analyses:
Mitigated Needs in
Service Contexts
Analyses:
Differences in Access
Attributed to Initiatives

3. Health Outcome Infrastructure Initiative – Paschane 2010© Page 3
2701 Health-Neutral Premiums Independent analysis of demographic-based variability
2701 Useful Quality Monitoring Iterative behavioral and organizational outcome factors
2703 Home-Based Healthcare Evidence-based standards for chronic and promotion care
2706 Shared Pediatric Outcomes Independent analysis of demographic-based variability
2713 Cover Prevention Services Updated evidence in effectiveness of prevention services
2717 Improve Health Outcomes Evidence-based standards for chronic and promotion care
3001 Hospital Value Monitoring Iterative behavioral and organizational outcome factors
3004 Long-Term Care Monitoring Iterative behavioral and organizational outcome factors
3007 Provider Quality Monitoring Iterative behavioral and organizational outcome factors
3011 National Outcomes Strategy Evidence-based standards for chronic and promotion care
3013 National Quality Monitoring Iterative behavioral and organizational outcome factors
3014 Public-Viewed Monitoring Evidence-based designs for consumer-tailored informatics
3021 Innovative System Models Evidence-based standards for chronic and promotion care
3022 Shared Panel Outcomes Independent analysis of demographic-based variability
3126 Innovative Rural Models Evidence-based standards for chronic and promotion care
3201 Shared Plan Outcomes Independent analysis of demographic-based variability
3306 Educate Poorer Groups Evidence-based designs for consumer-tailored informatics
3501 Innovative Quality Models Evidence-based standards for chronic and promotion care
3503 Medication Management Evidence-based standards for chronic and promotion care
3506 Educate Shared Decisions Evidence-based designs for consumer-tailored informatics
3510 Patient System Navigation Evidence-based designs for consumer-tailored informatics
4001 National Prevention Strategy Updated evidence in effectiveness of prevention services
4002 Fund Prevention Strategies Updated evidence in effectiveness of prevention services
4003 Combine Prevention Models Updated evidence in effectiveness of prevention services
4004 National Prevention Message Evidence-based designs for consumer-tailored informatics
4103 Individual Prevention Plans Evidence-based designs for consumer-tailored informatics
4104 Finance Prevention Services Updated evidence in effectiveness of prevention services
4201 Finance Health Promotion Evidence-based standards for chronic and promotion care
4206 High-Risk Prevention Plans Evidence-based designs for patient-tailored informatics
4301 Trend Health Disparities Independent analysis of demographic-based variability
5601 Finance Health Centers Iterative behavioral and organizational outcome factors
5602 Designate Shortage Areas Independent analysis of demographic-based variability
5605 National Access Monitoring Iterative behavioral and organizational outcome factors
General Plan of Action
The Initiative will benefit from the growing interest and numerous collaborations that are in
healthcare infrastructure nationally, and worldwide. The Initiative will fund a comprehensive
collaboration of academic, industry, government, and consumer application of healthcare
infrastructure research. The overarching method is to conduct short-term, recursive analyses
where innovative changes in healthcare infrastructure can reveal practical and transferable
knowledge to other places, under similar economic and institutional conditions.
Methodologically, the emphasis is on optimizing the availability of effective health care delivery
in places where the populations’ general health or survival, and community development is
undermined by chronically unresolved infrastructural weaknesses. Nevertheless, each resulting
model will demonstrate parameters and principles that are useful to other settings, such as

4. Health Outcome Infrastructure Initiative – Paschane 2010© Page 4
remote and rural or diverse and congested communities. The evidence of effects is multi-
dimensional, so likely to have broad, even global value as new infrastructural innovations are
made apparent to the research and policy communities at large.
The Initiative relies on a base of interdisciplinary sciences because of the complexity of
healthcare infrastructure. The figure below helps illustrate the reliance on a consortium of
interests to help reveal best practices and needs for continual research to strengthen any
healthcare infrastructure model.
Performance Architectural Science Systems
The President committed Federal departments to “use innovative tools, methods, and systems
to cooperate among themselves, across all levels of Government, and with nonprofit
organizations, businesses, and individuals in the private sector1
.” Furthermore, OMB policy is to
create and institutionalize a culture of open Government, one where the “integration of various
disciplines facilitates organization-wide and lasting change in the way the Government works,”
and the use of best practices “take advantage of the expertise and insight of people both inside
1
The White House, January 21, 2009, www.whitehouse.gov
Healthcare
Infrastructure
Industry
Services
OperationsProducts
Government
Policy
Programs
Oversight
Academia
Education
Analyses
Monitoring
Consumers
Preparation
Segmentation
Communication

5. Health Outcome Infrastructure Initiative – Paschane 2010© Page 5
and outside the Federal Government, and form high-impact collaborations with researchers,
the private sector, and civil society2
.”
The integrated framework for the Administration’ objectives is the Performance Architectural
Science Systems (PASS)3
that reinforce the maturity of (a) evidence-based management
cultures; (b) agile integration of methodological best-practices; (c) IT-enabled awareness,
training, and customer interactions; (d) incremental optimization of IT-enhanced business
services; (e) robust capacity for shared knowledge of outcome causes; and, (f) natural openness
to collaborative among communities of interest.
The long-term goal of a Federal Performance Architecture (FPA) is to fit applied scientific
methods to all communication and management environments, so as to sustain recursive
learning and collaboration of performance optimization across internal and external
organizations.
To achieve a robust and useful FPA, IT offices across the Federal government will need to
engineer, test, and validate recursive analytic methodological capacities (applied
interdisciplinary science) that are user- and organization-specific information services; enabled
and sustained through adaptive tools, IT-based training, and governance through communities
of interest. The goal of the analytic capacities is to build sound, incremental, and long-term
information sources for continuous improvements in operational effectiveness and efficiency,
service quality and benefit, and various causes of team capacity and organizational outcomes.
The basis of each analytic capacity is a Model Performance Architecture (MPA); an estimated
set of alternative performance causal pathways and workflow interactions based on classifying,
analyzing, translating, and monitoring of data regarding formal and informal behavioral,
organizational, and system processes. Each MPA is a baseline prototype of the analytic capacity
within a specific domain of organizational operations. Through recursive analysis, verification,
and validation, the MPA is engineered into a Segment Performance Architecture (SPA), fitted to
the cultural, functional, and educational needs of teams, managers, and decision-makers.
The SPA is categorically delimited from other operations to control for complex organizational
and human factors. Each SPA is a prospective candidate for a broader, integrated
Organizational Performance Architecture (OPA) that affects the routine work culture,
organizational strategy, and the general awareness of causes of outcomes. The OPA is
engineered into a web-based environment to facilitate continuous, intuitive interactions with
analyses. The web design facilitates awareness of outlier and pattern discoveries in
performance, and validation of utility among users at various levels of organizational functions.
An integrated OPA can provide key management functions, such as hierarchical representations
of awareness for executive and stakeholder audiences, and in-depth statistical modeling for
strategic planning across contexts, organizations, and people groups.
2
OMB M-10-06, December 8, 2009, www.omb.gov
3
PASS is a collaborative framework by SPARC technologist and UMBC methodologists.

6. Health Outcome Infrastructure Initiative – Paschane 2010© Page 6
Organizational Support
The Initiative would have to support and organize appropriate engineering (e.g., MPA, SPA,
OPA, and FPA) through levels, functions, and domains of the Federal government.
The proposed team is four principal investigators and seven staff to organize and promote the
research methodology to potential collaborators. The Emerging Healthcare Infrastructure Office
will be responsible for organizing, vetting, and funding targeted, cooperative research projects
consistent with the framework and scope of needs from the communities of interest.
Early Research Targets
The Acts include several useful components that can be strengthened in an FPA:
1. The CDC assessments on existing community-based chronic disease management programs
can be improved by expanding to population-based evidence of previous health services,
stratified to match the target populations—not only by age, but also by race, gender,
conditions, and other factors.
2. The CDC analyses of best practices in the application of prevention programs to health care
delivery systems can be integrated with research on contexts of service delivery and population
health risk.
3. The AHRQ planning of training for primary care providers in evidence-based practices of
prevention, promotion, and chronic disease care can be improved with continuous updates to
population-stratified prevention effectiveness analyses, and clinical-population standards of
care.
4. The CMS outreach and education assistance to low-income and aging populations provides
evidence-based guidance in the design of patient-tailored informatics, and this will require
online patient engagements that are sensitive to cultural, disease, age, educational, and
technological aspects of prevention and chronic care management.
5. The CMS analysis of health plans’ care management outcomes will be enhanced with
analyses of demographic-based variability in outcomes, attributable to the care standards
administered by plans.
Major Sustainable Benefits
A robust Federal Performance Architecture (FPA) will help ensure that the disparate changes to
the National health system are guided by evidence of their effects within the whole. This is a
necessary capacity that can only be achieved through the cooperation of methodological and
technological expertise. Not only the United States health consumers will benefit, but global

7. Health Outcome Infrastructure Initiative – Paschane 2010© Page 7
communities will benefit from the knowledge of health IT infrastructural research and modeling
into best practices.
Specifically, the research community will coordinate useful findings from clinical and
population-based data to provide (a) standards for chronic and promotion care, (b) updated
prevention service effectiveness, and (c) consumer centered informatics to deliver both. These
are the most likely concentrations for simultaneous improvements in quality, access, and
decreases in overall cost through health IT research.
The research will enable tailoring of services, messages, and methods to patients in ways that
meet their different needs and cultural interpretations of health. The research will also provide
evidence-based support for decision making in major activities affecting institutional and
societal goals. The on-going, public analyses encourage methodological visibility and data
accountability, and ensure that the evidence-based decisions are sound.
Ultimately, the FPA will coordinate evidence-based (a) standards of care, (b) health informatics,
(c) organizational effects, and (d) demographic fits, to meet the complex needs of health and
health processes.
For more information, please call David Paschane at 202-256-5763.