Prospects for Care Coordination Measurement Using Electronic Data Sources

Table 4. Near-term Measure Opportunities

Measurement Approach Specific Measure Concepts Data Source(s)
Use Meaningful Use measure data elements in new measures of care coordination Go to Tables 1, 2, and 3 for lists of data elements Certified EHRs from providers and hospitals participating in the Meaningful Use incentive program
Use CCD/CCR messages to confirm transmission of key pieces of information during care transitions CCD/CCR transmitted following hospital discharge or referral to specialist CCD/CCR sections for the medication list, problem list, lab results included among information transmitted. Contents of CCD/CCR not examined)

Numerator: EHR or HIE*

Denominator: claims data (APCD, HIE* [if includes claims data], payer files)

Use EHR data to confirm inclusion of key information from other health care settings within primary care record Primary care EHR contains information on hospitalization (e.g., discharge summary) or specialist visits (e.g., clinical summary) that occurred outside the primary care clinic system

Numerator: EHR

Denominator: claims data (APCD, HIE* [if includes claims data], payer files)

Use EHR audit files to evaluate whether information transferred from other settings is viewed by providers.

Discharge summary received from hospital is opened by PCP or nurse within certain timeframe.

Clinical summary from specialist consult is viewed before or during follow-up visit.

Numerator and denominator: EHR audit files
Use claims data to confirm follow-up care occurred within expected time frame Percent of patients discharged from the hospital with certain conditions who have a visit with an outpatient provider within a certain timeframe Numerator and denominator: APCDs or HIE* (if includes claims data) or payer files
Use claims data to examine instances of redundant testing
  • Repetition of a particular imaging study within a set timeframe: surrounding an inpatient admission for a particular diagnosis.
  • Ordered by different outpatient providers at visits with the same principal diagnosis.

Numerator and denominator: APCDs or HIE* (if includes claims data) or payer files

Would be enhanced by addition of clinical data from EHR or HIE*

APCD—all-payer claims database; CCD—continuity of care document; CCR—continuity of care record; EHR—electronic health record; HIE—health information exchange

*HIEs are only a data source if they include a data repository that stores data rather than just transmitting it.

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Page last reviewed October 2014
Internet Citation: Table 4. Near-term Measure Opportunities. October 2014. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/research/findings/final-reports/prospectscare/prosptab4.html