Appendix B: Group Panel Call Agenda
The following material was
distributed to all group call participants in advance of the calls, in order to
stimulate and support the discussion.
Coordination Measure Concepts
For Discussion of Data Issues
Our goal is to assess the
potential of measuring care coordination processes using data from various
health IT systems, such as electronic health records (EHR), health information
exchanges (HIE), and other sources such as all-payer claims databases. We are
interested in your thinking about measurement that would be feasible for a wide
range of practices or hospitals, not only those that are most advanced in their
use of health IT systems, although we are also interested in possibilities from
leaders in health IT implementation.
Although we are not
developing specific measure concepts at this time, as a foundation for our
group discussion, we developed two hypothetical measure concepts. We will use
these as concrete launching points to discuss issues and opportunities related
to particular kinds of information needed, corresponding data elements,
identification of denominator populations, standardization of data, and
feasibility. We are not interested in debating the merits of particular measure
concepts, but rather wish to focus on how data from health IT systems or other
sources could be used to measure concepts such as these. The hypothetical
measures are derived from preferred practices highlighted in a National Quality
Forum report on care coordination measurement,i but to our knowledge are not proposed as measures by any organization.
Below, we list general
questions to guide the discussion.
Questions for Discussion:
- Which aspects of the hypothetical
measures are the most feasible to implement currently using data from health IT
systems or other sources? Which are least feasible?
- What potential issues are there in
identifying the denominator populations?
- What barriers or challenges
currently exist in measuring these concepts?
- What needs to happen to overcome
- What might be possible in another
2-3 years, given the current rate of IT system implementation and expected
developments for other data sources?
Hypothetical Measure 1: Percent of practice
patients with chronic disease for whom a plan of care is documented in the
Based on NQF Preferred
Practice 6: Health care providers and
entities should have structured and effective systems, policies, procedures,
and practices to create, document, execute, and update a plan of care with
The plan of care
should be jointly created and managed by the patient, caregiver, and care
provider according to their preferences and the accountable provider. Elements
of the plan of care should include, but not be limited to:
- Patient's diagnosis or problem.
- Updated list of
- Appointments for follow-up care.
- Environmental or social factors that may
contribute to the problem.
- Other known factors that may contribute to
the problem, including assets and strengths.
- Plan of care to address the diagnosis or
problem, including preventive care.
- Documentation of the surrogate decisionmaker for patient care.
- Self-management training and/or skills identified by the patient.
- Evaluation of participation and level of
engagement in activities of daily living.
- Existence of
Numerator: Presence of a care plan that includes the above elements in the patient record.
The elements must be grouped together in a single location within the record,
such as a care plan document or template.
Denominator: Patients with a visit to the primary care practice within the last 3 years with
at least 3 encounters with any diagnosis of congestive heart failure (CHF),
asthma, diabetes, advanced coronary artery disease, chronic kidney disease or
chronic liver disease, or patients seen within the practice within the last 3
years who have been hospitalized within 12 months with a principal diagnosis of
one of these diagnoses.
Measure 2: Percent of
practice patients whose referral to a specialist physician was accompanied by
core transition data elements.
Based on NQF
Preferred Practice 22: Data elements should accompany the patient during all transitions of care and
should be appropriate to the type of transition and accessible throughout the
transition. These core data elements should include, but not be limited to:
- Medical diagnosis and
significant health problems.
- Clinical status.
- Medication lists.
completed within the setting.
- All treatments
(durable medical equipment [DME], medications, therapies) including
- Relevant past medical
- Functional status.
- Communication skills.
- Patient and caregiver
priorities for care.
- Preferences relevant
to the transition.
- Advance directive
Numerator: Presence of
the above elements in information or documentation sent by the primary care
provider to a specialist when referring a patient for a specialist consult. Documentation
must exist that the information was transmitted to the specialist
electronically or in hard copy within one week of referral, or no later than
the date of the specialist visit, whichever is sooner.
referred from the primary care practice to a non-practice specialist physician
within the last 12 months.
i. National Quality Forum (NQF). Preferred Practices and Performance Measures for Measuring and Reporting Care
Coordination: A Consensus report. Washington, D.C.: NQF; 2010.
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