At least 1 lab order uses
CPOE for 60% of unique patients who have at least 1 lab test result
Lab orders (recorded as
structured data through CPOE)
Lab orders could serve as a
denominator for measures pertaining to Information Transfer or Monitor,
Follow-up and Respond to Change
This is one element of a
measure addressing CPOE for medication, lab, and radiology orders.
Hospital labs provide
structured electronic lab results to outpatient providers for ≥40% of
electronic orders received, and use LOINC where available
Structured electronic lab
results coded using LOINC
Useful for numerator of
measures pertaining to Information Transfer and/or Facilitate Transitions
Specifications note that
further guidance is needed on where LOINC codes are available.
Clinical summaries provided
to patients for >50% of all office visits within 24 hours (pending
information should be available within 4 days of becoming available to EP)
Elements of clinical
summaries potentially of use:
- Problem list.
- Diagnostic/lab test orders
- Medication list.
- Medication allergy list.
- Reason for visit.
- Time/location next visit.
If captured in EHRs in a
structured way, elements of clinical summaries may be useful in the numerator
of measures of many different care coordination processes, including
Information Transfer, Facilitate Transitions Across Settings, Proactive Plan
of Care, and Establish Accountability/Negotiate Responsibility.
In addition, evidence of
timely transfer of clinical summaries may also be useful for measures related
to Information Transfer and Facilitate Transitions Across Settings, even if
data are not structured.
As with the related Stage I
Core measure, this does not specify recording or transmission of information
in a structured way.
Record and provide summary
of care record for >50% of transitions of care for referring EP or EH;
record care plan fields (goals and instructions) for 10% of patients; record
team member (including PCP, if available) for 10% of patients; for EH, 10% of
all discharges have care summary (including care plan and care team, if
available) sent electronically to EP or post-acute care provider
Summary of care record
Care plan fields
Team member (in particular
Summary of care record and
care summary may be useful for numerator of measures related to Information
Transfer, Facilitate Transitions Across Settings, and Proactive Plan Of Care.
Care plan fields may be
useful for numerator of measures pertaining to Proactive Plan Of Care and
Assess Needs and Goals.
Specification of team
member, in particular PCP, may be useful for denominator of any measure that
requires attribution of patients to a particular provider, or numerator of
measures pertaining to Establish Accountability/Negotiate Responsibility
More guidance is needed
regarding content of a summary of care record. Current measure
recommendations indicate this is under development.
Measure specifications do
not require use of structured data for any of these elements (including team
member), which would be desirable for use as quality measure data elements.
Care team members may be
required as structured data in Stage III (coded using National Provider
A dynamically maintained
shared care plan may be considered for Stage III.