Hospital Core Clinical Data Elements

This is not a measure. This is an electronic clinical quality tool intended to extract the first captured set of vital signs and basic laboratory results measured in adult patients admitted to acute care short stay hospitals. These data will be used with claims data to risk-adjust hospital outcome measures.

Limited proprietary coding is contained in these specifications for user convenience. Users of proprietary code sets should obtain all necessary licenses from the owners of the code sets.  

CPT(R) contained in the Measure specifications is copyright 2004-2013 American Medical Association. LOINC(R) copyright 2004-2013 Regenstrief Institute, Inc. This material contains SNOMED Clinical Terms(R) (SNOMED CT[R]) copyright 2004-2013 International Health Terminology Standards Development Organisation. ICD-10 copyright 2013 World Health Organization. All Rights Reserved.

These performance specifications are not clinical guidelines and do not establish a standard of medical care, and have not been tested for all potential applications.

THE MEASURES AND SPECIFICATIONS ARE PROVIDED AS IS WITHOUT WARRANTY OF ANY KIND.

Due to technical limitations, registered trademarks are indicated by (R) or [R] and unregistered trademarks are indicated by (TM) or [TM].

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Although we are using the "proportion" function in the Measure Authoring Tool, this is not a measure. The intent of this tool is to extract a set of clinical data elements from hospital EHRs and use them to risk adjust hospital outcome measures.  This work addresses concerns expressed by many stakeholders that data gathered directly from patients and used by clinicians to guide diagnostic decisions and treatment are preferable to data from claims derived from chart abstraction after a patient has been discharged. The core clinical data elements include the first set of vital signs and basic laboratory test results captured on adult hospitalized patients after they arrive at the hospital to which they are subsequently admitted. This first set of data values are often captured in the emergency department or in the pre-operative area sometimes hours before a patient is admitted to that same facility. The time of arrival is often captured in the patient management or registration database when patients have their first encounter with the hospitals’ administrative staff. These data elements were selected because they reflect patients' clinical status when they first present to the hospital, are relevant to patient outcomes, consistently obtained on adult inpatients based on current clinical practice; captured with a standard definition and recorded in a standard format across providers; and entered in structured fields that are feasibly retrieved from current EHR systems, The core clinical data elements also include some demographic data elements that are used as both risk adjustment variables as well as to link EHR data files with claims data to calculate measure results.

The purpose of this tool is to extract clinical data that are already routinely captured in EHRs among hospitalized adult patients. It is not intended to require that clinical staff perform additional measurements or tests that are not needed for diagnostic assessment or treatment of patients. This is not meant to guide or alter the care patients’ receive.

No actual measure score will be generated. These core clinical data elements will be combined with claims data and used to risk adjust hospital outcome measures.

Core Clinical Data Elements - CCDE

This tool supports extraction of the first-captured values for basic vital signs, weight, and the results of a complete blood count and basic chemistry panel for all patients directly admitted to the hospital or admitted to the same facility after an Emergency Department stay or surgical procedure. The tool also supports extraction of troponin level for patients admitted with acute myocardial infarction. The logic in this document supports extraction of the first vital signs captured within 2 hours of a patient having registered as arrived at the hospital and first laboratory test results captured within 24 hours of arrival. This timing is relative to the time a patient is registered in the electronic system as having arrived, usually by administrative staff and not relative to the time of admission. 
The first values are frequently captured before a decision or order to admit a patient, for example, in the Emergency Department or pre-operative area. Proper use of this tool requires mapping of first-captured values in these locations in addition to other inpatient locations for directly admitted patients.

To be determined

All patients age 65 and older with an inpatient admission (length of stay <=365 days) and Medicare as the payer during the measurement period.

Same as IP

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For patients in the denominator, report the first value for vital signs captured within 2 hours of arrival at the same facility to which the patient is subsequently admitted, and for laboratory test results within 24 hours of arrival. First values for the following data elements are captured in the Emergency Department or outpatient area before a patient is subsequently admitted to the same hospital or on an inpatient unit for directly admitted patients:
Heart rate
Systolic blood pressure
Diastolic blood pressure
Respiratory rate
Temperature
Oxygen saturation
Weight
Hemoglobin
Hematocrit
Platelet
White blood cell count
Potassium
Sodium
Chloride
Bicarbonate
BUN
Creatinine
Glucose
Troponin level

From initial time of hospital entry

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Patient date of birth
Gender