Connecting & Managing the Primary Care System
Introduction
Primary care organizations need timely clinical information to coordinate care, manage patients and populations, direct patients to appropriate settings, and reduce unnecessary, duplicative or poorly coordinated services. State leaders need information to manage and account for the system: where needs exist; whether workforce and delivery-system capacity are sufficient; how public and private resources are used; and whether access, quality, equity, outcomes, utilization and costs are improving. The information system must therefore support both patient care and statewide management and accountability. It also provides the information needed to coordinate the ongoing activities of the other eight Key Levers.
Building on the States’ Experience
Several states have developed statewide health information exchanges, all-payer claims databases, quality-reporting systems and health data utilities that provide much of the necessary foundation. These models demonstrate feasibility, but none identified in this review connects the clinical, workforce, financial, payer-compliance, investment and performance information needed to manage and continuously improve a statewide primary care system. The central recommendation of this article is that each state designate and finance one accountable entity to connect existing systems into a coherent statewide primary care information backbone.
Technology Expands the Possibilities
Advances in interoperability, data processing, automation and artificial intelligence increasingly make it possible to acquire, connect and interpret information historically divided among providers, payers, government agencies and reporting systems. These capabilities can reduce manual data collection, produce timelier information, identify emerging problems, support clinical decisions and patient follow-up, and relieve substantial clerical work.
Current evidence suggests that AI should be treated primarily as a workforce-support tool rather than a substitute for an adequate workforce or well-designed delivery system. It may reduce documentation and administrative burdens (OECD; McMaster Health Forum) and help clean and standardize electronic health records (EHR) data and identify incomplete or conflicting information (JMIR Medical Informatics). Because the field is evolving rapidly, these conclusions should remain provisional.
Persistent differences in internet access, language, disability, digital literacy and health literacy mean that patient-facing AI applications could widen disparities if they become the exclusive route to information or services (HHS Office of Disease Prevention and Health Promotion; JAMA Network Open). They should supplement, rather than replace, human assistance and non-digital means of access.
This article sets out the data, measurement and reporting objectives; the statewide information backbone needed to achieve them; relevant state models; and the requirements states should address in implementation.
Data, Measurement & Reporting Objectives
States invest in primary care to improve health and obtain greater value from healthcare spending. That requires two complementary capabilities: connecting the full spectrum of healthcare providers and managing the system to improve quality, outcomes and value. Specific objectives include:
Connect providers to improve patient care and value. Connect primary care practices, specialists, hospitals, laboratories, pharmacies and other participants so clinicians have timely information to coordinate care, improve quality, manage patients and populations, direct patients to the most appropriate setting, and reduce unnecessary, duplicative or poorly coordinated care.
Provide state government and the public with a clear account of whether the statewide strategy is being implemented and achieving its goals. Give the governor, legislature, responsible state leaders and the public a common, high-level account. This should include statewide progress in access, quality, morbidity and mortality; payer participation and compliance; the percentage of payments made through risk-adjusted capitation; investment and capacity development; organizational stability; and the results of state interventions. It should show where policy decisions, additional resources or corrective action are required.
Track payer participation and compliance. Show how each payer and payer category is performing against state goals and requirements for primary care spending, use of risk-adjusted capitation, data submission and other applicable responsibilities. Reporting should identify which payers are participating, which are falling short, by how much and whether their performance is improving. It should also show the effect of payer performance on the resources available to strengthen primary care.
Provide state agencies, regional bodies, primary care organizations and practices with the information needed to manage and improve performance. Show how the system is performing, where needs, deficiencies and underperformance exist, and what factors are contributing to them. Results should be examined by service area, provider organization, practice, disease or diagnosis, and population characteristics such as race, ethnicity, age, income and coverage. This information should reveal problems involving access, workforce, capacity, quality, utilization, outcomes, disparities and costs; guide corrective action; and show whether those actions produce improvement.
Motivate providers to continuously improve. Provide valid comparative information that allows provider organizations and practices to assess their performance against goals, peers and leading performers. Comparative and public reporting should create motivation to improve, identify successful practices worth spreading, and allow the state to determine whether improvement efforts are producing results.
Identify where resources may be needed and inform allocation decisions. Use measures such as whether residents have a usual source of care, whether they received primary care during the preceding year, disease prevalence, hospital admissions, emergency department use, workforce and delivery-system capacity, quality and health outcomes to signal populations, service areas, provider organizations and practices warranting further investigation, assistance or investment. Provide responsible decision-makers with the basis for determining whether and how to allocate or redirect workforce, payment, technical assistance, capital and other resources, and show whether the resulting investments reduce gaps and improve performance.
Employ automation and AI to improve care, increase productivity and provide more timely reporting. Acquire information directly from existing source systems and automate its collection, extraction, preparation, reconciliation and transmission. Use AI, subject to appropriate validation and clinical oversight, to assist clinical decision-making and diagnosis, identify patterns and anomalies, support patient follow-up such as scheduling and testing, and summarize complex findings. These capabilities can reduce administrative burdens, free clinician and staff time for patient care, and help the existing workforce serve more patients effectively. Faster information flows should produce more current reports, while maps, dashboards, trends, comparisons, alerts and drill-down capabilities should help users interpret those reports quickly and determine whether and how to respond.
The Statewide Primary Care Information Backbone
State healthcare systems typically consist of competing organizations and information systems that communicate unevenly. Connections developed by providers, payers and vendors have created valuable capabilities, but their reach reflects organizational boundaries and limited financial resources. Small, rural, safety-net and other underfunded practices are least able to purchase the interfaces and services they need. Reporting programs have often compounded the problem by specifying what providers must submit while leaving each practice to extract, prepare and transmit the information, adding clerical work and diverting time from patient care.
Currently and for the foreseeable future, neither claims nor EHR data is sufficient by itself. Claims provide relatively standardized information about services, utilization and spending but limited clinical detail; EHRs provide richer clinical information but may be incomplete, inconsistent and confined to particular organizations or networks. The backbone should therefore link and validate both sources, using each for the purposes for which it is best suited.
Creating a statewide network requires a sponsor with statewide responsibility, authority and financing capacity. The state should determine common information needs, establish standards, ensure participation and invest in shared, largely automated connections that every primary care organization can use. State sponsorship can build on existing agencies, health information exchanges, payer and provider systems, and private vendors. Its distinct role is to ensure that the components work together and that statewide capability reaches areas where private investment has been insufficient. This targeted public infrastructure investment is essential to team care, quality measurement, statewide management and public accountability.
The remainder of this section describes what a statewide information backbone should accomplish.
Facilitating Team Care by Creating a Statewide Network
The larger purpose of connecting providers is to enable primary care organizations to coordinate the full course of each patient’s care. As Toussaint, Shortell and Wadsworth argued in “Better Care Teams: A Key Element of Better Care Plans,” multidisciplinary provider teams need the capacity to provide or arrange necessary care, coordinate it across providers and settings, and accept responsibility for its quality, outcomes and cost. The information backbone provides the connections needed to make that responsibility operational.
Team care requires a statewide network connecting primary care organizations and practices with one another and with specialists, hospitals, laboratories, pharmacies and other participants in patient care. Each primary care organization should maintain a current view of where its patients are receiving care, by whom, what care has been provided and what follow-up is required.
Quality Measurement and Continuous Improvement
The backbone should provide the data and reporting infrastructure for the statewide quality-measurement and continuous-improvement system described in Key Lever 9. It should acquire clinical information largely automatically from EHRs, laboratories, pharmacies, health information exchanges and surveys; combine it with claims and utilization data; and produce timely results at statewide, service-area, population, organization and practice levels.
To make comparisons valid, the state should standardize and validate data, apply consistent attribution and measure calculation, align payer and program requirements around a small set of meaningful measures, and qualify results when data limitations could mislead. The backbone should return comparable results to organizations and practices and make them available for public reporting. Key Lever 9 determines how the results are used to support improvement.
Financial Reporting and Payer Compliance
The information backbone should connect payer, payment, organizational-finance and investment information. It should show whether each payer is meeting state goals and requirements for primary care spending, risk-adjusted capitation and data submission; how funds entering primary care are distributed and used; what capacity and results those resources produce; and whether the financial condition of any primary care organization or practice threatens continued access or service capacity.
Primary Care System Management and Resource Allocation
The backbone should enable state agencies, regional bodies, primary care organizations and practices to identify gaps in access, workforce, capacity, quality and organizational stability; determine where corrective action or additional resources are needed; and assess whether those actions improve performance.
Public Accountability
The information backbone should make reliable, understandable information about access and quality available to patients, employers, purchasers, policymakers and the public. Statewide reporting should show whether access and health outcomes are improving, including regular sources of care, morbidity, mortality, healthy days, and avoidable hospital and emergency-department use. Comparative reporting should allow the public to assess the relative quality of provider organizations and practices through measures of clinical quality, continuity, prevention, chronic-disease management and patient experience.
State Responsibility
The state should assume responsibility for ensuring that the information backbone functions as a coherent statewide network. It should:
- Establish common definitions, interoperability requirements, and standards for accurate patient and provider matching and data provenance.
- Require appropriate participation by payers, providers, vendors and other data holders to the extent permitted by state and federal law.
- Govern role-based access, audit trails, consent where required, protection of sensitive information, cybersecurity, and permitted primary and secondary uses of data.
- Ensure that information is sufficiently complete, timely and usable.
- Finance the shared infrastructure and connections required for participation.
- Monitor whether the network supports the state’s primary care goals.
The state should ensure that primary care practices can obtain information essential to patient care, quality measurement and public reporting without purchasing duplicative interfaces or negotiating separately with multiple vendors. Particular functions may be performed by state agencies, health information exchanges, all-payer claims databases, primary care organizations, payers or qualified vendors, while the state remains accountable for the network as a whole.
Illustrative State Models
Judged against this framework, states vary widely in how far they have actually progressed. Twenty-five states have mandatory all-payer claims databases operating or in implementation, several more with voluntary databases or efforts to establish one. And health information organizations were already exchanging clinical data in 47 states as of 2023, though often only regionally or locally rather than statewide.
Maryland and Wisconsin illustrate two of the most developed approaches identified in this review, building essential components through two different organizational approaches. Maryland has developed a relatively integrated, state-designated health data utility, while Wisconsin relies on a federated arrangement in which specialized organizations perform different functions. These models demonstrate feasibility and provide practical starting points rather than complete blueprints.
No state identified in this review has fully integrated clinical exchange, primary care workforce and capacity, payer compliance, organizational financial stability, investment tracking, quality improvement, and public accountability into the unified primary care information and management framework proposed here.
Maryland: A State-Designated Health Data Utility
Maryland’s CRISP provides the clearest existing precedent for an integrated statewide information backbone. CRISP has evolved from a health information exchange into Maryland’s designated Health Data Utility. It connects clinical records, hospital encounters, laboratory results, claims, medication information, public health information, and social needs data for clinical care, population analysis, and state reporting.
Real-time clinical alerts: CRISP’s Encounter Notification Service and newer CEND solution deliver real-time alerts about hospital encounters and can also generate alerts concerning health factors such as A1c levels, diabetes risk and social determinants of health.
Care coordination: ENS/CEND are explicitly built to notify PCPs and care coordinators of hospital events so they can coordinate follow-up care.
Population analysis: CRISP Reporting Services combines administrative and clinical data to support population analysis and the design and measurement of interventions.
Primary care reporting: CRISP operates the Maryland Primary Care Program Reporting Suite and a Multi-Payer Reporting Suite for participating practices, providing information on quality, utilization and cost across Medicare and Medicaid populations.
Broader state efforts on cost, quality, and population health: the July 2025 re-designation filing describes CRISP supporting Hospital Global Budget Revenue, the Episode Quality Improvement Program, MDPCP, HSCRC quality reporting, and state-level cost/quality dashboards.
Maryland demonstrates that statewide infrastructure can develop incrementally as state responsibilities expand. A comprehensive primary care backbone would build on these capabilities by incorporating the delivery-system, workforce, payer-compliance, organizational-finance, investment, and statewide performance information described in this key lever.
Wisconsin: A Federated Model
Wisconsin illustrates how important statewide information functions can be distributed among specialized organizations.
- WISHIN is Wisconsin’s state-designated health information exchange and operates a statewide clinical exchange platform connecting more than 2,000 sites of care.
- The Wisconsin Collaborative for Healthcare Quality aggregates and validates patient-level clinical information from participating provider organizations, calculates comparable organization- and clinic-level results, publicly reports performance, and supports collaborative improvement.
- The Wisconsin Health Information Organization (WHIO) operates Wisconsin’s voluntary all-payer claims database for analysis of spending, utilization, access, variation and total cost.
- WHIO and WCHQ: According to Wisconsin’s 2019 WHIO Annual Report, WHIO and WCHQ formed 360ValuCounts to combine claims and clinical data for statewide value reporting. Wisconsin’s 2024 WHIO Annual Report describes additional multi-source data marts developed by WHIO for particular projects. These efforts remain project-based rather than comprehensive and do not include WISHIN’s statewide clinical exchange.
Together, these organizations provide important components of a statewide information backbone, but their capabilities have not been integrated into a single ongoing system.
Other States
According to a federal review commissioned by the Office of the Assistant Secretary for Planning and Evaluation and conducted by RAND, 25 states have mandatory all-payer claims databases operating or under implementation. The APCD Council’s current state inventory identifies several additional states with voluntary databases or efforts to establish one.
There is no comparable national count of statewide EHR databases because states generally rely on health information exchanges that connect independently maintained clinical records rather than creating one centralized repository. According to a national survey conducted by the federal Office of the National Coordinator for Health Information Technology, health information organizations were exchanging clinical information in 47 states in 2023, although many operated regionally or locally rather than statewide.
Implementation
Legislation and implementation planning for the statewide information backbone should address the following requirements
Designate one agency, authority or state-sponsored organization to be responsible for the complete backbone. Consistent with the governance structure described in Key Lever 3, its governance should provide structured participation for representatives of primary care clinicians, patients, rural and safety-net providers, payers, purchasers and technical experts. Its mandate should extend across agency, program and task-force boundaries. It should have the authority and funding to obtain information and cooperation from state entities; secure participation by payers, providers, vendors and other data holders; and ensure that the backbone works statewide. It should maintain common definitions, data-quality standards, access rules and a focused set of measures while monitoring reporting burdens and the usefulness of the information produced.
Define the core reporting domains. The complete reporting system should cover:
- Population need: Current and projected health needs, unmet demand and populations or geographic areas experiencing disproportionate need.
- Access: Whether residents have a regular source of care and can obtain appropriate care when needed.
- Delivery-system capacity: Effective clinical capacity, team composition, scope of services and essential practice capabilities.
- Workforce: Supply, distribution, vacancies, turnover, recruitment, retention, training pipelines and expected retirements.
- Utilization and continuity: Use of primary and preventive care, continuity and comprehensiveness, and avoidable hospital and emergency-department use.
- Quality and outcomes: Clinical quality, patient experience, care coordination, population health outcomes and disparities.
- Financing and investment: Primary care spending, payment methods, public and private investment, and the capacity and results those resources produce.
- Organizational stability and structural change: Financial condition, practice openings and closures, ownership and affiliation changes, consolidation and reductions in service.
Identify the information and source systems that must be connected. These include EHRs, health information exchanges, claims databases, workforce and provider registries, payer and payment systems, patient surveys, and financial, quality and investment-reporting systems. The state should specify the information required from each source, how it is defined and how frequently it must be updated. Information should be acquired and transmitted largely automatically to reduce manual work by providers.
Implementation should begin with an inventory and gap analysis of existing exchanges, claims databases, registries, reporting systems and contractual connections. The state should build on and connect existing assets rather than automatically create a new centralized database, proceeding through a phased integration plan supported by sustainable financing for infrastructure, operations and practice connections.
Give state leaders a clear report on the condition of primary care. The governor, legislature and responsible state executives should receive a concise scorecard from one authoritative source. It should separately show:
- Payer spending and compliance
- State goals and progress
- Population need and equity
- Access, workforce and delivery-system capacity
- Investment and capacity development
- Organizational stability and structural change
- Quality and health outcomes
- Emerging risks and actions required
The scorecard should allow state leaders to follow the accountability chain from payer spending, through investment and capacity development, to changes in access, equity, quality and health outcomes. Payer spending should remain distinct from how the resulting funds are invested and what those investments produce. State leaders should work from the same facts.
Provide reporting at several levels. The same underlying information should support:
- Statewide reporting for executive and legislative oversight.
- Regional and primary care service-area reporting to reveal geographic differences hidden by statewide results.
- Population-level reporting to identify differences and disparities among groups.
- Organization- and practice-level reporting to support management, improvement, technical assistance and decisions about resources.
Reports should be tailored to the responsibilities of state agencies, regional bodies, primary care organizations, practices, care teams, payers, purchasers and the public while preserving common definitions and results.
Identify problems and prompt corrective action. Reporting should allow users to move from statewide results to the regions, service areas, populations, provider organizations and practices contributing to them. An interactive map should provide a practical geographic gateway. Results should be examined by characteristics such as race, ethnicity, language, age, income, coverage, disability and rurality. For significant problems or examples of superior performance, reports should identify the populations affected, contributing factors, responsible organizations and actions underway. Urgent warning indicators should be delivered to the responsible officials and organizations, and subsequent reporting should show what action was taken and whether performance improved.
Show performance trends and comparisons. Major results should be presented with an adopted target, accepted standard, comparison or baseline, together with trends over time. Reports should explain limitations involving risk adjustment, patient attribution, sample size, data completeness and differences among populations or service areas.
Specify reporting frequency. Reports should be produced as frequently as reliable information becomes available and management decisions require. The state should publish an annual report on overall progress, provide quarterly or monthly management reports on measures requiring closer monitoring, and issue timely alerts about urgent conditions such as practice closures, loss of capacity or unusual changes in hospital and emergency-department use.
Public reporting. The state should publish understandable information about access, quality, comparative provider performance, health outcomes, disparities and the results of public investment. Organization- and practice-level comparisons should be published only when results meet adopted standards for sample size, patient attribution, risk adjustment, data completeness and statistical reliability. Results that do not meet those standards should be suppressed, aggregated or clearly qualified. Published reports should be accompanied by definitions, measure specifications, methods and explanations of important limitations. More detailed information should remain available to authorized users under appropriate privacy, security and data-use controls.
Public reporting should do more than provide transparency. As Wadsworth, Shortell and Toussaint argued in Publicly Reported Health Outcomes: A National Initiative To Improve Care, it should help provider organizations improve performance, purchasers strengthen their provider networks, and patients make more informed choices. Wisconsin’s experience supports that expectation: comparative public reporting was associated with improvement among participating physician groups and helped focus their quality-improvement efforts. Public reporting can therefore do more than disclose how the system performs; it can help drive better performance.
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Articles on the other eight Key Levers can be found at https://www.linkedin.com/pulse/nine-key-levers-framework-implementing-states-primary-wadsworth-yxemc/
Selected References
Maryland Health Care Commission. Re-Designation of CRISP as the State-Designated Health Information Exchange. July 17, 2025.
Massachusetts Executive Office of Health and Human Services and Massachusetts eHealth Institute. Introduction to the Mass HIway. December 9, 2015.
Massachusetts Center for Health Information and Analysis. “Massachusetts All-Payer Claims Database.”
Michigan Health Information Network Shared Services. Harnessing Data for Better Health.
Rhode Island Department of Health. “Health Information Exchange.”
Vermont General Assembly. “Vermont Information Technology Leaders.” 18 V.S.A. § 9352.
Greer, Ann Lennarson. Embracing Accountability: Physician Leadership, Public Reporting, and Teamwork in the Wisconsin Collaborative for Healthcare Quality. Commonwealth Fund, 2008.
Khurshid, Anjum, and Indra Neil Sarkar. “The Health Data Utility and the Resurgence of Health Information Exchanges as a National Resource.” Journal of the American Medical Informatics Association 32, no. 5 (2025): 964–967.
Bari, Lisa, Kate Ricker, Heidi Penix, and Jolie Ritzo. Health Data Utility Framework: A Guide to Implementation. Civitas Networks for Health and Maryland Health Care Commission, 2023.
Blewett, Lynn A., Natalie Schwehr Mac Arthur, and James Campbell. “The Future of State All-Payer Claims Databases.” Journal of Health Politics, Policy and Law 48, no. 1 (2023): 93–115.
Hersh, William R., et al. “Outcomes from Health Information Exchange: Systematic Review and Future Research Needs.” JMIR Medical Informatics 3, no. 4 (2015): e39.
National Academies of Sciences, Engineering, and Medicine. Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care. Washington, DC: National Academies Press, 2021.
Jabbarpour, Yalda, et al. The Health of US Primary Care 2025 Scorecard: The Cost of Neglect. Milbank Memorial Fund and The Physicians Foundation, 2025.
Song, Zirui, Wayne Altman, Renee Crichlow, and Kevin Grumbach. “Primary Care as a Public Utility: The Case for a Common Fund.” JAMA, published online May 20, 2026.
Wadsworth, Peter A., Stephen M. Shortell, and John S. Toussaint. “Publicly Reported Health Outcomes: A National Initiative to Improve Care.” Health Affairs Forefront, July 19, 2022.
Lamb, Geoffrey C., Maureen A. Smith, William B. Weeks, and Christopher Queram. “Publicly Reported Quality-of-Care Measures Influenced Wisconsin Physician Groups to Improve Performance.” Health Affairs 32, no. 3 (2013): 536–543.
Fung, Constance H., Yee-Wei Lim, Soeren Mattke, Cheryl Damberg, and Paul G. Shekelle. “Systematic Review: The Evidence That Publishing Patient Care Performance Data Improves Quality of Care.” Annals of Internal Medicine 148, no. 2 (2008): 111–123.
Prang, Khic-Houy, Roxanne Maritz, Hana Sabanovic, David Dunt, and Margaret Kelaher. “Mechanisms and Impact of Public Reporting on Physicians and Hospitals’ Performance: A Systematic Review (2000–2020).” PLOS ONE 16, no. 2 (2021): e0247297.
Share, David A., et al. “How a Regional Collaborative of Hospitals and Physicians in Michigan Cut Costs and Improved the Quality of Care.” Health Affairs 30, no. 4 (2011): 636–645.