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Anticipate Data Challenges and Opportunities

What is this and why does it matter?

Data is essential for tracking progress, identifying disparities, and refining your health equity efforts—but poorly planned collection and inconsistent definitions can undermine your initiative.

Common challenges to anticipate include:

Addressing these proactively positions your team to collect high-quality, actionable data from the start.

How should you work through this component?

Begin with the Anticipate Data Needs and Opportunities Base Deck, which helps your team connect health equity to quality improvement through data. It covers strategies for choosing a health equity focus, applying an intersectional lens, partnering with community stakeholders, and navigating common data challenges.

Then work through the following resources:

When does it make sense to work through this component?

Build data considerations into your initiative from the start. If your team struggles to measure impact or encounters unexpected discrepancies, pause and refine your data strategy to stay aligned with your equity goals.

Curriculum to be completed for this component:

Anticipate Data Needs and Opportunities (Base Deck-Presentation)

A foundational presentation connecting health equity to quality improvement, covering how to choose a health equity focus, apply an intersectional lens, partner with community stakeholders to collect and interpret data, and develop concrete data action items and next steps.

RIC – EE – ADNO – Anticipate Data Needs and Opportunities (base deck) 6.2025Download

Measurement for Health Equity: Data, Performance, Metrics, VBP (Presentation)

A presentation covering how to measure the impact of health equity interventions by selecting meaningful metrics, improving demographic data quality, and aligning equity goals with value-based payment models—including guidance on setting performance targets and designing payment approaches that reward equity-focused care.




RIC – EE – ADNO – Data VBP and measurement presentation.03.24.23 (3)Download

Anticipating Data Needs and Opportunities Tool

A guided worksheet that walks teams through five data action items—identifying data sources, reviewing initial data, earning data access buy-in, navigating data sharing logistics, and developing an analysis plan—with a next steps table to document tasks, timelines, and responsibilities.




RIC – EE – ADNO – Health Equity Data Opportunities and Action Items Tool 06.2025Download

Consideration for Accessing, Collecting, and Sharing Data Tool

A planning guide structured around three core questions—whose buy-in you need, what data to collect, and how to use it—addressing staff training, privacy and security, cross-partner data consistency, and sustainable data-sharing practices throughout the initiative.








RIC – EE – ADNO – Accessing Collecting and Sharing Data Tool 6.2025Download

Self-Assessment Topics and Questions:

This self-assessment tool will help you identify, anticipate and address common challenges implementing the Roadmap.  Using it will increase your chances of successfully reducing and eliminating health and healthcare inequities. Each Roadmap component will have a set of questions and topics in their respective sections; AHE recommends utilizing the assessment questions in two ways:

  1. What are the data-related opportunities that the team would like to pursue?
  1. Are there data-related challenges that the team has already run into?*
    • How did the team respond to the challenge?
  1. What are the current process and/or outcome metrics that the team is already using or considering?*
    • Please describe.
  1. Has the team identified the key stakeholders that are necessary for mid- and long-term support or sustainability of the initiative?  Note that these stakeholders can often be different individuals, teams, or working groups than stakeholders needed for the initial stages of the initiative.
    • Has the team asked these stakeholders to identify the key metrics or measures of success that would inform their decision about whether or not to continue supporting the initiative or sustaining it over the long-term?
      • Do the initiative’s goals and objectives incorporate these metrics or measures of success?
      • Does the initiative’s data collection and analysis plan incorporate these metrics and measures of success?
  1. Which key information technology and data analytics colleagues are a part of the team?
    • Please describe which partner organization employs them.
    • Please describe their role(s) on the team.
  1. Has the team assessed the quality of the baseline data needed to operate the initiative’s care transformation?**
    • Please describe the measures/metrics needed to operate the initiative’s care transformation.
      • For each, please describe the team’s understanding of how much of the data is complete, missing, or declined.
        • How did the team assess this?
      • For each, please describe the team’s understanding of the measures/metrics quality/accuracy.
        • How did the team assess this?
          • Please describe the strategies that the team is using to counteract potential sources of incomplete or inaccurate data.
  1. Has the team assessed the quality of the baseline data needed to operate the initiative’s payment model?**
    • Please describe the measures/metrics needed to operate the initiative’s payment model.
      • For each, please describe the team’s understanding of how much of the data is complete, missing, or declined.
        • How did the team assess this?
      • For each, please describe the team’s understanding of the measures/metrics quality/accuracy.
        • How did the team assess this?
          • Please describe the strategies that the team is using to counteract potential sources of incomplete or inaccurate data.
  1. Has the team assessed how the following might undermine their assumptions regarding their initiative’s care transformation and payment model or the metrics and data that will be used to implement and evaluate it?
    • Patients moving in and out of specific payer status, resulting in loss or inconsistency of claims data.
    • Boundary Crossing: Patients receiving care in different or neighboring geographic regions (e.g., outside of an accountable care organization/coordinated care organization boundary to which they are assigned), multiple locations within a larger health system, or from different health systems over time.
    • Lack of post-referral follow-up.
    • Lack of inter-agency data transfer or sharing.
  1. Has the team fully developed and run test reports before initiating the initiative to ensure that all data necessary for the full functioning of the care transformation and payment model can be entered, accessed and analyzed as needed?

Goal and Objective Setting:

About the Roadmap Goal and Objective Setting Tool

This tool is designed to facilitate goal setting and completion for your team. The tool will allow your team to:

1) Record goals that align with the various Roadmap components; 

2) Record objectives, time frames, and target completion dates, among other important items for each goal; and 

3) Monitor progress of goals per Roadmap component

Your team is welcome to engage with this tool as much or as little as it would like, and is helpful, in the development, implementation, and evaluation of your health equity initiative. We encourage you to use this tool to ensure clear goal setting and promote consistent communication, accountability, and progress within your team. This tool is designed to be used over time as your team progresses through the Roadmap and your initiative. This is in no way intended to be used one way by all teams. This is meant to help you progress through the Roadmap component(s) on which you are working at a given time and you may reach your goals in any order. We welcome you to consult your AHE TA lead on getting started with this tool.

Each Roadmap component is listed as a separate tab. Navigate to the desired Roadmap component via the task bar at the bottom of the spreadsheet to add, edit, or view goals. Hide certain tabs as needed to narrow your view to specific Roadmap components or the snapshot. Changing the status of a goal will automatically shift the Snapshot view for the specific Roadmap component.