One Organization's Experience Automating Quality Measurement using a
Commercial Electronic Medical Record.

A health system signed a contract to install an electronic health record
system-wide. One of their goals was to automate quality reporting and
eliminate chart review. As part of the installation planning process,
they hired a consultant and formed a project team including key vendors
and internal staff to develop requirements for automating quality
reporting. The project team evaluated HQA measures, JCAHO core measures
and a subset of Surgical Care Improvement Project (SCIP) measures. The
results were as follows:

\- of the data elements evaluated, approximately 60% could be automated
using their planned EHR system;

\- another 17.5% of the data elements could be partially automated using
their planned EHR, reducing the chart review burden

\- the last 22.5% of the data elements could not be automated, largely
due to documentation requirements.

**Automating 60% of the data elements would result in automation of only
4 quality measures**.

Please direct questions to Kristine Martin Anderson at
Anderson_kristine_m@bah.com

The pages that follow provide examples of data elements in each
category, *for this health system's implementation of this vendor's
product*. .

**Table 1: Data Elements that could be automated Using the planned
Electronic Health Record**

  -------------------------------------------------------------------------
  **Data element**                                             **Measures
                                                               Impacted**
  ------------------------------------------------------------ ------------
  Admission Date *(for specific information see General Data   30
  Elements section)*                                           

  Birthdate *(for specific information see General Data        30
  Elements section)*                                           

  ICD-9-CM Principal Diagnosis Code *(for specific information 29
  see General Data Elements section)*                          

  ICD-9-CM Other Procedure Code                                20

  ICD-9-CM Principal Procedure Codes                           17

  Admission Source *(for specific information see General Data 14
  Elements section)*                                           

  Discharge Status *(for specific information see General Data 13
  Elements section)*                                           

  Arrival Date/Time                                            12

  Transfer From Another ED                                     11

  Antibiotic Name:\                                            8
  \                                                            
  (EACH antibiotic dose administered from hospital admission   
  through 48 hours post-op (72 hours post-op if it's a CABG or 
  Other Cardiac Surgery                                        

  Antibiotic Administration Date/TIME                          8

  Discharge Date *(for specific information see General Data   7
  Elements section)*                                           

  Antibiotic Administration Route                              5

  Antibiotic Allergy\                                          4
  \                                                            
  Definition: Documentation that the patient has an allergy,   
  sensitivity, or intolerance to penicillin, beta lactams, or  
  cephalosporins. An allergy can be defined as an acquired,    
  abnormal immune response to a substance, (allergen) that     
  does not normally cause a reaction.                          

  Adult Smoking History                                        3

  Adult Smoking Counseling                                     3

  Surgery Performed During Stay                                3

  Antibiotics During Stay:\                                    3
  \                                                            
  Definition: Documentation that the patient received          
  antibiotics during this hospital stay. This refers to the    
  time period from arrival through the first 48 hours after    
  the surgery end time                                         

  Surgery Start Date;\                                         3
  The date the procedure of interest started.                  

  Surgical Incision Time                                       3

  Type of Surgery:\                                            3
  The classification of the surgical procedure, selected as    
  the procedure of interest, which was performed during the    
  admission and is consistent with at least one corresponding  
  value in the data element ICD-9-CM Principal Procedure Code  
  or ICD-9-CM Other\                                           
  Procedure Codes.                                             

  Oral Antibiotics:\                                           3
  \                                                            
  Documentation that the only antibiotic combinations          
  administered prior to hospital arrival or more than 24 hours 
  prior to incision were either oral Neomycin Sulfate +        
  Erythromycin Base or oral Neomycin Sulfate + Metronidazole.  

  ICU Transfer or Admission Within 24 Hours                    3

  HIV positive (Compromised)                                   3

  AIDS (Compromised)                                           3

  Cystic fibrosis (Compromised                                 3

  Aspirin allergy                                              2

  ACEI allergy                                                 2

  ARB allergy                                                  2

  Beta blocker allergy                                         2

  Pacemaker                                                    2

  Heart rate                                                   2

  Heart rate Date/Time                                         2

  Prophylactic Antibiotic\                                     2
  \                                                            
  Definition: The antibiotic dose administered as a            
  prophylaxis during the admission. An antibiotic may be       
  defined as any drug, such as penicillin or streptomycin,     
  containing any quantity of any chemical substance produced   
  by a microorganism or made synthetically (i.e., quinolones)  
  which has the capacity to inhibit the growth of or destroy   
  bacteria and other microorgansims. Antibiotics are used in   
  the prevention and treatment of infectious diseases          

  Surgery End Date /Time\                                      2
  Definition: The date the procedure of interest ended.        

  Discharge Time                                               2

  VTE Surgery Start Date                                       2

  VTE Surgical Incision Time                                   2

  VTE Surgery End Date                                         2

  VTE Prophylaxis                                              2

  ARB prescribed at discharge                                  2

  ACEI prescribed at discharge                                 2

  Aspirin Received Within 24 Hours Before Hospital Arrival     1

  Coumadin/warfarin pre-arrival                                1

  Aspirin (date, time)                                         1

  Bradycardia (heart rate less than 60 bpm) on day of          1
  discharge or day prior to discharge                          

  Second or third degree heart block on ECG on arrival or      1
  during hospital stay                                         

  Bradycardia (heart rate less than 60 bpm) on arrival or      1
  within 24 hours after arrival                                

  Beta Blocker Name                                            1

  Beta Blocker Date/Time                                       1

  ABG Date/TIME                                                1

  ABG Done                                                     1

  Initial Blood Culture Collection Date/Time                   1

  Blood Culture Collected After Arrival                        1

  Antibiotic Received                                          1

  VTE Prophylaxis Low Dose Unfractionated Heparin Received     1

  VTE Prophylaxis Low Molecular Weight Heparin Received        1

  VTE Prophylaxis Intermittent Pneumatic Compression Devices   1
  Received                                                     

  VTE Prophylaxis Factor Xa Inhibitor Received                 1

  VTE Prophylaxis Warfarin Received                            1

  VTE Prophylaxis Received Date/Time                           1

  VTE Timely                                                   1

  Preop Hair Removal                                           1

  VTE Procedure of Interest                                    1

  Intraop Death:                                               1

  Coumadin/warfarin prescribed at discharge                    1

  Aspirin prescribed at discharge                              1

  Beta blocker prescribed at discharge                         1

  Discharge Instructions Address Activity                      1

  Discharge Instructions Address Diet                          1

  Discharge Instructions Address Follow-up                     1

  Discharge Instructions Address Medications                   1

  Discharge Instructions Address Symptoms Worsening            1

  Discharge Instructions Address Weight Monitoring             1
  -------------------------------------------------------------------------

**Table 2: Data Elements that could be partially automated using the
planned Electronic Health Record**

+-----------------+--------------------------+-------+----------------+
| **Data          | **Current Data           | **Mea | **Comments**   |
| element**       | Location**               | sures |                |
|                 |                          | Impac |                |
|                 |                          | ted** |                |
+=================+==========================+=======+================+
| Pneumonia       | Any ED documentation     | 9     |                |
| Working         | (includes ED/Outpatient  |       |                |
| Diagnosis on    | Registration form, or    |       |                |
| Admission       | triage record), H&P,     |       |                |
|                 | Nursing admission        |       |                |
|                 | assessment/admitting     |       |                |
|                 | note, Observation        |       |                |
|                 | record, Procedure notes  |       |                |
+-----------------+--------------------------+-------+----------------+
| Admission       | Coding Sheet, Face       | 4     | This data      |
| Diagnosis of    | Sheet, UB-92, Field      |       | element could  |
| Infection\      | Location: 76             |       | be derived     |
| \               |                          |       | from the ICD-9 |
| Definition: An  |                          |       | codes listed   |
| admission       |                          |       | in             |
| diagnosis       |                          |       | specifications |
| ICD-9-CM code   |                          |       | Appendix A,    |
| suggestive of   |                          |       | Table 5.09     |
| preoperative    |                          |       | this table     |
| infectious      |                          |       | lists          |
| disease.        |                          |       | Diagnosis      |
|                 |                          |       | Codes          |
|                 |                          |       | suggestive of  |
|                 |                          |       | preoperative   |
|                 |                          |       | infection.     |
|                 |                          |       | Recommend      |
|                 |                          |       | working this   |
|                 |                          |       | one into       |
|                 |                          |       | Surgical Order |
|                 |                          |       | sets to be     |
|                 |                          |       | captured       |
|                 |                          |       | e              |
|                 |                          |       | lectronically. |
|                 |                          |       | For now, use   |
|                 |                          |       | ICD-9 codes    |
|                 |                          |       | for infection  |
+-----------------+--------------------------+-------+----------------+
| Antibiotics     | Any source documenting   | 4     | Same day       |
| Prior to        | antibiotic               |       | surgery admits |
| Arrival\        | administrations\         |       | will be using  |
| \               | Emergency department     |       | the health     |
| Definition:     | record\                  |       | history and    |
| Documentation   | EMT/Ambulance records\   |       | should be      |
| in the medical  | History and Physical\    |       | updating home  |
| record that the | ICU flowsheet\           |       | medications.   |
| patient         | IV flowsheet             |       | Date & time    |
| received        |                          |       | can be         |
| antibiotics     | Medication               |       | captured in    |
| within 24 hours | administration record\   |       | the comment    |
| prior to        | Nursing notes\           |       | field but is   |
| hospital        | Consultation notes\      |       | not codied. -  |
| arrival         | History and physical\    |       | Need to list   |
|                 | Nursing admission        |       | Home Meds as   |
|                 | assessment\              |       | data element.  |
|                 | Pre-anesthesia           |       | Need to look   |
|                 | assessments\             |       | for within 24  |
|                 | Pre-operative            |       | hours.         |
|                 | assessments              |       |                |
+-----------------+--------------------------+-------+----------------+
| Prior           | Admission face sheet,    | 3     | Could have     |
| hospitalization | Consultation notes,      |       | been           |
| within 14 days  | Discharge summary,       |       | hospitalized   |
| (Compromised)   | Emergency department     |       | at another     |
|                 | record, History and      |       | hospital and   |
|                 | physical, Nurse          |       | not picked up  |
|                 | admission notes          |       | by a previous  |
|                 |                          |       | encounter;     |
|                 |                          |       | primary        |
|                 |                          |       | exclusion      |
|                 |                          |       | criteria       |
+-----------------+--------------------------+-------+----------------+
| Systemic        | Admission face sheet,    | 3     | Dependent upon |
| chemotherapy    | Consultation notes,      |       | system review  |
| within last 3   | Discharge summary,       |       | versus use of  |
| months          | Emergency department     |       | problem list . |
| (Compromised)   | record, History and      |       | We need to     |
|                 | physical, Nurse          |       | make these     |
|                 | admission notes          |       | separate as we |
|                 |                          |       | currently have |
|                 |                          |       | the history    |
|                 |                          |       | carry forward  |
|                 |                          |       | to next        |
|                 |                          |       | encounter.     |
|                 |                          |       | Chemo is #1    |
|                 |                          |       | reason for     |
|                 |                          |       | imm            |
|                 |                          |       | unosuppression |
+-----------------+--------------------------+-------+----------------+
| Systemic        | Admission face sheet,    | 3     | See Appendix   |
| im              | Consultation notes,      |       | C, Table 2.2   |
| munosuppressive | Discharge summary,       |       | for            |
| therapy within  | Emergency department     |       | comprehensive  |
| last 3 months   | record, History and      |       | list of        |
| (Compromised)   | physical, Nurse          |       | Imm            |
|                 | admission notes          |       | unosuppressive |
|                 |                          |       | medications\   |
|                 |                          |       | See above,     |
|                 |                          |       | systemic       |
|                 |                          |       | chemotherapy   |
|                 |                          |       | Steroids -     |
|                 |                          |       | reason for     |
|                 |                          |       | imm            |
|                 |                          |       | unosuppression |
+-----------------+--------------------------+-------+----------------+
| Leukemia        | Admission face sheet,    | 3     | Dependent upon |
| documented      | Consultation notes,      |       | system review  |
| within last 3   | Discharge summary,       |       | versus use of  |
| months          | Emergency department     |       | problem list.  |
| (Compromised)   | record, History and      |       | We need to     |
|                 | physical, Nurse          |       | make these     |
|                 | admission notes          |       | separate as we |
|                 |                          |       | currently have |
|                 |                          |       | the history    |
|                 |                          |       | carry forward  |
|                 |                          |       | to next        |
|                 |                          |       | encounter.     |
|                 |                          |       | Usually have   |
|                 |                          |       | chemo.         |
+-----------------+--------------------------+-------+----------------+
| Blood Pressure  | Ambulance record,        | 1     | Shock = BP     |
|                 | Emergency department     |       | \<90 systolic  |
|                 | record, H&P, Nursing     |       |                |
|                 | admission assessment,    |       |                |
|                 | Transfer sheet, Progress |       |                |
|                 | notes, Nursing notes,    |       |                |
|                 | Consultant notes         |       |                |
+-----------------+--------------------------+-------+----------------+
| Blood Pressure  | Ambulance record,        | 1     | Shock = BP     |
| Date/Time       | Emergency department     |       | \<90 systolic  |
|                 | record, H&P, Nursing     |       |                |
|                 | admission assessment,    |       |                |
|                 | Transfer sheet, Progress |       |                |
|                 | notes, Nursing notes,    |       |                |
|                 | Consultant notes         |       |                |
+-----------------+--------------------------+-------+----------------+
| Shock on        | Ambulance record,        | 1     | Shock = BP     |
| arrival or      | Emergency department     |       | \<90 systolic  |
| within 24 hours | record, H&P, Nursing     |       |                |
| after arrival   | admission assessment,    |       |                |
|                 | Transfer sheet, Progress |       |                |
|                 | notes, Nursing notes,    |       |                |
|                 | Consultant notes         |       |                |
+-----------------+--------------------------+-------+----------------+
| Pulse Oximetry  | Emergency department     | 1     | ED will        |
| Date/Time       | record, Nursing          |       | document pulse |
|                 | admission                |       | oximetry on    |
|                 | assessment/admitting     |       | the triage     |
|                 | note, Observation        |       | form. After    |
|                 | record, Procedure notes, |       | initial        |
|                 | RT notes, Vital signs    |       | assessment,    |
|                 | graphic record           |       | will be on     |
|                 |                          |       | paper until    |
|                 |                          |       | patient        |
|                 |                          |       | admitted to    |
|                 |                          |       | floor or ICU.  |
|                 |                          |       | Part of VS.    |
+-----------------+--------------------------+-------+----------------+
| Pulse Oximetry  | Consultation notes,      | 1     | If Pulse       |
| Done            | Discharge summary,       |       | Oximetry date, |
|                 | Emergency department     |       | time (i, j) -  |
|                 | record, H&P, Nursing     |       | Arrival date,  |
|                 | notes, Physician orders  |       | time (d, e)    |
|                 |                          |       | \<= 24 hours   |
|                 |                          |       | then Yes. Part |
|                 |                          |       | of VS          |
+-----------------+--------------------------+-------+----------------+
| Pneumococcal    | V03.82 Need for          | 1     | All responses  |
| Vaccination     | prophylactic vaccination |       | present except |
| Status          | and inoculation against  |       | for medically  |
|                 | bacterial diseases --    |       | c              |
|                 | Streptococcus pneumoniae |       | ontraindicated |
|                 | {pneumococcus} OR V06.6  |       | because of     |
|                 | Need for prophylactic    |       | bone marrow    |
|                 | vaccination and          |       | transplant     |
|                 | inoculation against      |       | within the     |
|                 | bacterial diseases --    |       | past 12        |
|                 | Streptococcus pneumoniae |       | months. Bone   |
|                 | {pneumococcus} and       |       | marrow         |
|                 | influenza may be coded   |       | transplant     |
|                 | at discharge. May be     |       | rare.          |
|                 | coupled with 99.55       |       |                |
|                 | Prophylactic             |       |                |
|                 | administration of        |       |                |
|                 | vaccine against other    |       |                |
|                 | diseases.\               |       |                |
|                 | Any ED documentation     |       |                |
|                 | (includes ED\            |       |                |
|                 | triage record), Nursing  |       |                |
|                 | admission                |       |                |
|                 | as                       |       |                |
|                 | sessment/admitting/other |       |                |
|                 | note, MAR, Observation   |       |                |
|                 | record, Progress notes,  |       |                |
|                 | Discharge summary        |       |                |
+-----------------+--------------------------+-------+----------------+
| Influenza       | The ICD-9-CM codes now   | 1     | All responses  |
| Vaccination     | include V codes for      |       | present except |
| Status          | prophylactic vaccination |       | for medically  |
|                 | against Influenza\       |       | c              |
|                 | (V04.8 Need for          |       | ontraindicated |
|                 | Influenza vaccination    |       | because of     |
|                 | and inoculation was      |       | bone marrow    |
|                 | given; and V06.6 Needs   |       | transplant     |
|                 | for both\                |       | within the     |
|                 | Pneumococcal and         |       | past 12        |
|                 | Influenza vaccination    |       | months. Bone   |
|                 | and both inoculations    |       | marrow         |
|                 | were given). Programmers |       | transplant     |
|                 | may want to include this |       | rare.          |
|                 | in the measures'         |       |                |
|                 | algorithm so that        |       |                |
|                 | hospitals, if they wish, |       |                |
|                 | can take advantage of    |       |                |
|                 | this efficiency. May     |       |                |
|                 | also be coupled with     |       |                |
|                 | 99.52 Prophylactic       |       |                |
|                 | vaccination against      |       |                |
|                 | influenza.\              |       |                |
|                 | Any ED documentation     |       |                |
|                 | (includes ED\            |       |                |
|                 | triage record), Nursing  |       |                |
|                 | admission                |       |                |
|                 | as                       |       |                |
|                 | sessment/admitting/other |       |                |
|                 | note, MAR, Observation   |       |                |
|                 | record, Progress notes,  |       |                |
|                 | Discharge summary        |       |                |
+-----------------+--------------------------+-------+----------------+
| Glucose POD1    | Consultation notes\      | 1     | The blood      |
|                 | Diabetic flow sheet\     |       | glucose level  |
|                 | Laboratory reports\      |       | on             |
|                 | Nursing graphic sheets\  |       | postoperative  |
|                 | Nursing notes\           |       | day one        |
|                 | PACU/recovery room       |       | (POD 1) with   |
|                 | record\                  |       | Surgery End    |
|                 | Progress notes           |       | Date being     |
|                 |                          |       | postoperative  |
|                 |                          |       | day zero (POD  |
|                 |                          |       | 0), drawn      |
|                 |                          |       | closest to     |
|                 |                          |       | 6:00 A.M.      |
|                 |                          |       | (06:00).\      |
|                 |                          |       | \              |
|                 |                          |       | Some of the    |
|                 |                          |       | sites are      |
|                 |                          |       | capturing this |
|                 |                          |       | e              |
|                 |                          |       | lectronically, |
|                 |                          |       | some may not   |
|                 |                          |       | be. Not sure   |
|                 |                          |       | finger stick   |
|                 |                          |       | is captured.   |
+-----------------+--------------------------+-------+----------------+
| Glucose POD2    | Consultation notes\      | 1     | The blood      |
|                 | Diabetic flow sheet\     |       | glucose level  |
|                 | Laboratory reports\      |       | on             |
|                 | Nursing graphic sheets\  |       | postoperative  |
|                 | Nursing notes\           |       | day two (POD   |
|                 | PACU/recovery room       |       | 2) with        |
|                 | record\                  |       | Surgery End    |
|                 | Progress notes           |       | Date being     |
|                 |                          |       | postoperative  |
|                 |                          |       | day zero (POD  |
|                 |                          |       | 0), drawn      |
|                 |                          |       | closest to     |
|                 |                          |       | 6:00 A.M.      |
|                 |                          |       | (06:00).\      |
|                 |                          |       | \              |
|                 |                          |       | Some of the    |
|                 |                          |       | sites are      |
|                 |                          |       | capturing this |
|                 |                          |       | e              |
|                 |                          |       | lectronically, |
|                 |                          |       | some may not   |
|                 |                          |       | be. Not sure   |
|                 |                          |       | finger stick   |
|                 |                          |       | is captured.   |
+-----------------+--------------------------+-------+----------------+

**Table 3: Data Elements that could not be automated using the planned
Electronic Health Record**

  ----------------------------------------------------------------------------
  **Data element**   **Current Data      **Measures   **Comments**
                     Location**          Impacted**   
  ------------------ ------------------- ------------ ------------------------
  Infection Prior to History and         5            Is the patient receiving
  Anesthesia\        Physical, Operative              antibiotics via IV, PO,
  \                  report, Progress                 NG/PEG?\
  Definition:        notes, Emergency                 If yes does the patient
  Documentation the  department record,               have a documented
  patient was being  ICU flow sheet, IV               infection?\
  treated for an     flow sheet, MAR,                 Bloodstream infection\
  infection prior to Nursing notes                    Bone infection\
  the first surgical                                  Cellulitis\
  procedure of                                        H.pylori, if being
  interest performed                                  treated with
  during this                                         antibiotics\
  hospital stay.                                      Osteomyelitis\
                                                      Other documented
                                                      infection\
                                                      Pneumonia or other lung
                                                      infection\
                                                      Surgical site or wound
                                                      infection\
                                                      Urinary tract infection
                                                      (UTI)

  Pseudomonas risk   Admitting physician 3            • Accept only
                     orders, Admitting                physician/nurse
                     progress notes,                  practitioner/physician
                     Consultation notes,              assistant documentation
                     Emergency                        when determining if
                     department record,               bronchiectasis is
                     History and                      considered on
                     physical, Physician              admission.\
                     admission note,                  • Do not include
                     Progress notes.                  information from
                                                      consultation notes or
                                                      physician progress notes
                                                      written later than
                                                      admission, even if dated
                                                      the day of, or the day
                                                      after admission for
                                                      bronchiectasis.\
                                                      • Only use consultation
                                                      notes if they are
                                                      documented as completed
                                                      in the emergency
                                                      department for
                                                      bronchiectasis.\
                                                      • One time use or one
                                                      course of antibiotics or
                                                      corticosteroids is not
                                                      considered chronic
                                                      (Broad concept)

  Active bleeding on H&P, Consultation   2            Currently Physician
  arrival or during  notes, Discharge                 documentation is not in
  hospital stay      summary, Emergency               scope.\
                     department record,               Research for other
                     Nursing notes,                   options to capture
                     Physician orders                 electronically.

  Moderate or severe H&P, Consultation   2            Currently cardiology
  aortic stenosis    notes, Discharge                 documentation is not in
                     summary, Emergency               scope for
                     department record,               implementation. Research
                     ECHO reports,                    for other options to
                     Nursing notes,                   capture electronically.
                     Physician orders                 

  Physician, nurse   H&P , Consultation  2            Currently Physician
  practitioner, or   notes, Discharge                 documentation is not in
  physician          summary, Emergency               scope.\
  assistant          department record,               Research for other
  documentation of a Nursing notes,                   options to capture
  reason for not     Physician orders                 electronically.
  prescribing an                                      
  ACEI at discharge                                   

  Physician, nurse   H&P , Consultation  2            Currently Physician
  practitioner, or   notes, Discharge                 documentation is not in
  physician          summary, Emergency               scope.\
  assistant          department record,               Research for other
  documentation of a Nursing notes,                   options to capture
  reason for not     Physician orders                 electronically.
  prescribing an ARB                                  
  at discharge                                        

  LVSD; LVEF less    Consultation notes, 2            Currently cardiology
  than 40% or a      Discharge summary,               documentation is not in
  narrative          Emergency                        scope for
  description of LVS department record,               implementation. May be
  function           H&P, Nursing notes,              being captured in other
  consistent with    Physician orders,                systems\
  moderate or severe echocardiogram;                  Research for other
  systolic           radionuclide                     options to capture
  dysfunction        ventriculogram                   electronically. There
                                                      are a variety of systems
                                                      and software housing
                                                      this information. Each
                                                      facility would need to
                                                      evaluate potential
                                                      electronic option.

  ECG Date/Time      ECG report,         2            Currently cardiology
                     Progress notes,                  documentation is not in
                     Nurse's notes                    scope for
                                                      implementation. May be
                                                      being captured in other
                                                      systems\
                                                      Research for other
                                                      options to capture
                                                      electronically. There
                                                      are a variety of systems
                                                      and software housing
                                                      this information. Each
                                                      facility would need to
                                                      evaluate potential
                                                      electronic option.

  ST segment         ECG report,         2            Currently cardiology
  elevation          Progress notes                   documentation is not in
                                                      scope for
                                                      implementation. May be
                                                      being captured in other
                                                      systems\
                                                      Research for other
                                                      options to capture
                                                      electronically. There
                                                      are a variety of systems
                                                      and software housing
                                                      this information. Each
                                                      facility would need to
                                                      evaluate potential
                                                      electronic option.

  Left bundle branch ECG report,         2            Currently cardiology
  block (LBBB)       progress notes                   documentation is not in
                                                      scope for
                                                      implementation. May be
                                                      being captured in other
                                                      systemsResearch for
                                                      other options to capture
                                                      electronically. There
                                                      are a variety of systems
                                                      and software housing
                                                      this information. Each
                                                      facility would need to
                                                      evaluate potential
                                                      electronic option.

  Thrombolytic       Ambulance record,   2            Currently cardiology
  administration     Emergency                        documentation is not in
                     department record,               scope for
                     H&P, MAR, Nursing                implementation. May be
                     admission                        being captured in other
                     assessment,                      systems\
                     Transfer sheet                   Research for other
                                                      options to capture
                                                      electronically. There
                                                      are a variety of systems
                                                      and software housing
                                                      this information. Each
                                                      facility would need to
                                                      evaluate potential
                                                      electronic option.

  Contraindication   Consultation notes, 2            Part of Physician doc,
  to VTE Prophylaxis Physician orders,                not in scope
                     Physician progress               
                     notes, Procedure                 
                     notes, Surgery                   
                     record                           

  VTE Laparoscope    • Anesthesia        2            ICD-9-CM codes may not
                     evaluation\                      be a reliable source to
                     • Consultation                   determine if the
                     notes\                           procedure was performed
                     • History and                    entirely by laparoscope.
                     physical\                        Therefore, it is
                     • Operating room                 recommended that
                     record\                          abstractors refer to the
                     • Physician orders\              Suggested Data Sources\
                     • Physician                      Not part of
                     progress notes                   documentation

  Documented         • Anesthesia        2            Definition: Any
  Bleeding Risk      evaluation\                      condition documented by
                     • Consultation                   the physician, nurse
                     notes\                           practitioner, physician
                     • Discharge                      assistant, or certified
                     summary\                         registered nurse
                     • Emergency                      anesthetist that places
                     department record\               the patient at risk for
                     • History and                    bleeding such that it
                     physical\                        contraindicates an order
                     • Operative report\              for pharmacologic venous
                     • Physician orders\              thromboembolism
                     • Physician                      prophylaxis\
                     progress notes                   \
                                                      Part of Physician
                                                      documentation - out of
                                                      scope

  Contraindication   Consultation notes, 1             
  to Aspirin on      Discharge summary,               
  Arrival, Other     Emergency                        
  contraindication   department record,               
  documented by      H&P, Nursing notes,              
  physician, nurse   Physician orders                 
  practitioner or                                     
  physician                                           
  assistant                                           

  Other              Consultation notes, 1            Currently Physician
  contraindication   Discharge summary,               documentation is not in
  documented by      Emergency                        scope.\
  physician, nurse   department record,               Research for other
  practitioner or    H&P, Nursing notes,              options to capture
  physician          Physician orders                 electronically.
  assistant for not                                   
  prescribing                                         
  aspirin at                                          
  discharge                                           

  Other              Consultation notes, 1            Currently Physician
  contraindication   Discharge summary,               documentation is not in
  documented by      Emergency                        scope.\
  physician, nurse   department record,               Research for other
  practitioner or    H&P, Nursing notes,              options to capture
  physician          Physician orders                 electronically.
  assistant for not                                   
  prescribing a beta                                  
  blocker at                                          
  discharge                                           

  Contraindication                       1            Currently Physician
  to Beta Blocker on                                  documentation is not in
  Arrival                                             scope.\
                                                      Research for other
                                                      options to capture
                                                      electronically.

  Other reasons      Emergency           1            Currently Physician
  documented by a    department record,               documentation is not in
  physician, nurse   H&P, MAR, Nursing                scope.\
  practitioner, or   admission                        Research for other
  physician          assessment,                      options to capture
  assistant for not  Transfer sheet,                  electronically.
  giving beta        Progress notes,                  
  blocker within 24  Nursing notes,                   
  hours after        Consultant notes                 
  hospital arrival                                    

  Thrombolytic       Ambulance record,   1            Currently cardiology
  administration     Emergency                        documentation is not in
  date/Time          department record,               scope for
                     H&P, MAR, Nursing                implementation. May be
                     admission                        being captured in other
                     assessment,                      systems\
                     Transfer sheet                   Research for other
                                                      options to capture
                                                      electronically. There
                                                      are a variety of systems
                                                      and software housing
                                                      this information. Each
                                                      facility would need to
                                                      evaluate potential
                                                      electronic option.

  First PCI          Procedure note,     1            Currently cardiology
  Date/Time          Progress note                    documentation is not in
                                                      scope for
                                                      implementation. May be
                                                      being captured in other
                                                      systems\
                                                      Research for other
                                                      options to capture
                                                      electronically. There
                                                      are a variety of systems
                                                      and software housing
                                                      this information. Each
                                                      facility would need to
                                                      evaluate potential
                                                      electronic option.

  LVF Assessment     • Consultation      1            In the absence of
                     notes• Diagnostic                explicit documentation
                     test reports•                    that an LVSF assessment
                     Discharge                        was done, it should be
                     instruction sheet•               inferred that an
                     Discharge planning               assessment was done if:
                     notes• Discharge                 o An echocardiogram,
                     summary• Emergency               appropriate nuclear
                     department record•               medicine test, or a
                     History and                      cardiac catheterization
                     physical• Operative              with a left
                     notes• Physician                 ventriculogram was done
                     orders• Procedure                during this hospital
                     notes• Progress                  stay, oro There is
                     notes                            documentation one of the
                                                      above diagnostic tests
                                                      was performed anytime
                                                      prior to arrival (e.g.,
                                                      "Echo done last March"),
                                                      oro There is
                                                      documentation of LVSF,
                                                      either as an ejection
                                                      fraction or a narrative
                                                      qualitative description
                                                      (e.g., "Pt. admitted
                                                      with severe LV
                                                      dysfunction"). For
                                                      inclusion criteria refer
                                                      to Appendix H, Table 1.2
                                                      LVSF Assessment
                                                      Inclusion Table in the
                                                      Specifications Manual
                                                      for National Hospital
                                                      Quality Measures

  Date of Infection\ • Consultation      1            Currently Physician
  \                  note\                            documentation is not in
  Definition: The    • Discharge                      scope.\
  date of the first  summary\                         Research for other
  postoperative      • Progress notes                 options to capture
  infection.                                          electronically.

  Temperature        • ICU notes\        1            Documentation of
  Obtained           • PACU/recovery                  temperature (recorded in
                     room record\                     Fahrenheit) obtained
                     • Vital sign                     within the first hour
                     graphic record                   after leaving the
                                                      operating room.\
                                                      \
                                                      On paper in OR and PACU

  Temperature Value  • ICU notes\        1            The degree of hotness or
                     • PACU/recovery                  coldness of the body
                     room record\                     recorded in Fahrenheit.\
                     • Vital sign                     \
                     graphic record                   \
                                                      On paper in OR and PACU

  Temperature        • ICU notes•        1            The degree of hotness or
  Date/Time          PACU/recovery room               coldness of the body
                     record• Vital sign               recorded in
                     graphic record                   Fahrenheit.On paper in
                                                      OR and PACU
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