R e s e a r c h a n d a p p l i c a t i o n s Table 2 Frequency of clinical information and locations in electronic charts for quality measurement Name of measure and brief description Screening measures (patients for the denominator are identiﬁed by their age and gender) Breast cancer screening Female patients $40 years of age N Diagnostic order and result for who received a mammogram in the mammogram (543) past 2 years Description of denominator (D) or numerator (N) data element (no of eligible charts) Recognized for quality measurement Location Procedures 29 10.7 No % Location Not recognized for quality measurement Scanned patient docs Diagnostic imaging Other BMI documented (3122) Vitals 3116 99.8 Medical history Inﬂuenza vaccination documented (480) Immunizations 475 99.0 Chief complaint/HPI Smoking status documented (3357) Smart form 1796 53.4 BMI Inﬂuenza vaccine Smoking status Patients $18 years of age who have a BMI measured in the past 2 years Patients >50 years of age who received a ﬂu shot in the past year Smoking status updated annually in patients $18 years of age Intervention measures Antithrombotic therapy Patients $18 years of age with a diagnosis of IVD or $40 years of age with a diagnosis of diabetes taking aspirin or another antithrombotic therapy BP control Patients 18e75 with a diagnosis of hypertension, with or without IVD, with a recorded systolic BP <140 mm Hg and diastolic BP <90 mm Hg in the past 12 months (<130 mm Hg and 80 mm Hg in patients with hypertension and DM) Cholesterol screening and control High risk Screening: Patients 18e75 years of age with a diagnosis of dyslipidemia and DM or IVD with a measured LDL in the past year Control: Screened patients with LDL <100 mg/dl General population Screening: M 35+, F45+ w/no DM/IVD with a measured total cholesterol or LDL in the past 5 years Control: Screened patients with total cholesterol <240 mg/dl or LDL <160 mg/dl Hemoglobin A1c screening and control Screening: Patients 18e75 years of age with a diagnosis of DM with a documented hemoglobin A1c test within the past 6 months Control: Screened patients with hemoglobin A1c <7% N N N D D N D D N D D N N D N 623 250 757 1497 93 3866 1112 477 182 91.6 82.5 99.7 89.3 78.8 99.9 75.1 92.6 86.3 Other Procedures Social history Other Medical history Medical history Assessment Chief complaint/HPI Medical history Assessment Chief complaint/HPI Plan/treatment Medical history Assessment Chief complaint/HPI Medical history Assessment HPI Medical history Assessment Medical history Medical history Assessment Chief complaint/HPI Medical history Assessment Chief complaint/HPI Medical history Assessment Chief complaint/HPI Other Medical history Other Medical history Medical history Assessment Chief complaint/HPI Other No 270 204 10 1530 157 2 4 3 2 26 5 42 11 45 4 7 1 2 11 11 28 10 24 1 1 2 86 12 30 27 6 2 1 1 24 1 24 1 48 12 4 % 48.7 36.8 3.6 0.1 0.1 0.6 0.4 45.5 0.8 0.2 14.9 6.2 1.6 0.6 2.3 0.3 0.3 9.4 0.7 0.7 5.1 1.8 0.2 0.9 0.1 5.8 0.8 20.3 5.8 1.2 0.4 0.5 0.5 12.8 45.6 1.0 0.0 44.7 0.9 0.0 6.5 1.6 0.5 36.6 0.4 269 18.2 171 2 Continued Diabetes diagnosis and age $40 years (680) IVD diagnosis (303) Appropriate medication prescribed (759) Medications Hypertension diagnosis (1676) Problem list Comorbid diagnoses D Diabetes (551) Comorbid diagnoses D Diabetes (515) IVD (211) IVD (118) BP documented (3868) Dyslipidemia diagnosis (1468) Problem list Problem list Problem list Vitals Problem list Problem list Problem list Problem list 512 92.9 LDL cholesterol test result (2425) Laboratory tests 1294 53.4 Scanned patient docs 1106 Total cholesterol test result (2545) Laboratory tests 1383 53.4 Scanned patient docs 1137 Diabetes diagnosis (740) Problem list 676 91.4 Hemoglobin A1c test result (642) Laboratory tests 294 63.0 Scanned patient docs 606 J Am Med Inform Assoc 2012;19:604e609. doi:10.1136/amiajnl-2011-000557