Core Measures: All About the Data

Author:

Jane Metzger, Donna Schmidt, RN

Quality reporting and quality management present many challenges to hospitals today, and the data requirements for quality measures are at the crux of making improvements. Having the patient-specific information required for core measures in electronic form not only benefits quality reporting, but also enables real-time quality management.

We deconstructed the medical and surgical core measures into the data elements to examine the types of information and the sources in the inpatient EHR. Typical hospital core systems do provide some of the needed information, but much of the remainder must be derived from physician documentation. This finding reinforces the importance of using concurrent, electronic clinical surveillance and making full use of the additional information that becomes available with each new increment to the EHR . It also suggests that hospitals reconsider the typical sequencing of physician documentation late in the EHR roll-out, especially History and Physical, problem list and medication reconciliation.

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