Appendix 5: One-Page Summary Template

SNAC-recommended Initial Core Set, September 18, 2009

Measure Summary: CHIPRA Core Set Candidate Measures

1. Control #:
2. Measure Name:
3. Measure Definition
   1. Numerator:
   2. Denominator:
4. Measure Type:
   ____  Process ____  Outcome ____  Structure ____  Efficiency

5. Measure collected using:
   ____ EMR ____ CPOE ____  Other HIT ____ N/A ____ NR

   VALIDITY

6. Evidence of measure validity submitted?
   ____ Yes ____ No
7. Level of evidence supporting the measure (if submitted): (see Oxford University CEBM Levels of Evidence)
   __________________________________________________ 

8. USPSTF Grade if applicable:
   __________________________________________________ 

   FEASIBILITY

9. Measure Specifications Submitted?
   ____  Yes ____ No____ Yes, but insufficient detail provided
10. Data Source:
    ____ Admin____  MR____ Survey____ Other (specify):____ NR
11. Evidence of measure reliability submitted?
    ____ Yes____ No

12. List of entity types currently using measure:
    __________________________________________________ 

    IMPORTANCE

13. Addresses area of care mandated in legislation?
    ____ Yes (specify): __________________________________________________ ____ No
14. Documented variation in performance (by race/ethnicity, language spoken, insurance type, etc)?
    ____ Yes____ No____ NR
15. Measure used/data are collected in racial/ethnic populations other than non-Hispanic white?
    ____ Yes____ No____ NR