Prospects for Care Coordination Measurement Using Electronic Data Sources

Table 3. Meaningful Use Measures With Data Elements Potentially Useful for Care Coordination Measurement: Stage II Recommended Measures


Data Elements of Interest

Potential Use*


Stage II Recommended Measures

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 Across Settings

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 and/or results.
  • Medication list.
  • Medication allergy list.
  • Reason for visit.
  • Procedures.
  • Immunizations.
  • 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 PCP)

Care summary

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 Identifier)

A dynamically maintained shared care plan may be considered for Stage III.

CAH—critical access hospital; CPOE—computerized physician order entry; EH—eligible hospital; EHR—electronic health record; EP—eligible provider; LOINC—Logical Observation Identifiers Names and Codes; MU—Meaningful Use; ONC—Office of the National Coordinator; PCP—primary care provider.

*See the Care Coordination Measures Atlas for a list of activities hypothesized to be important for coordinating care.3 These activities are contained with the care coordination measurement framework.

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Page last reviewed October 2014
Page originally created September 2012
Internet Citation: Table 3. Meaningful Use Measures With Data Elements Potentially Useful for Care Coordination Measurement: Stage II Recommended Measures. Content last reviewed October 2014. Agency for Healthcare Research and Quality, Rockville, MD.