Prospects for Care Coordination Measurement Using Electronic Data Sources

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.

Hypothetical Care Coordination Measure Concepts

For Discussion of Data Issues and Opportunities


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 those challenges?
  • 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 patient record.

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 every patient.

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 medications.
  • 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 advance directives.

Measure 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.

Measure 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.

Hypothetical 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.
  • Treatments/procedures completed within the setting.
  • All treatments (durable medical equipment [DME], medications, therapies) including post-transitions treatments.
  • Relevant past medical history.
  • Functional status.
  • Communication skills.
  • Patient and caregiver priorities for care.
  • Preferences relevant to the transition.
  • Advance directive status.

Measure 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.

Measure Denominator: Patients 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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Page last reviewed July 2018
Page originally created September 2012
Internet Citation: Appendix B: Group Panel Call Agenda. Content last reviewed July 2018. Agency for Healthcare Research and Quality, Rockville, MD.
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