Attachment I - List of Varfor EHR Ext OPD Visits 010616

Attachment I: List of Variables for EHR Extraction of Outpatient Department Visits

National Hospital Care Survey:

Variables for Outpatient Visits

Your hospital can participate in the National Hospital Care Survey by submitting electronic health record (EHR) information in one of two ways:

1. A standardized minimum data set of Patient Encounter-Based data such as ONE of the following:

• Continuity of Care Document (CCD)

• Transition of Care Summary

• Discharge Summary

OR:

2. Data extracted from your hospital’s EHR or data repository consisting of:

   1. Needed data elements related to a patient visit

   2. A small set of Patient Encounter-Based personal identifiable information (PHI)

   3. If available, “Like to Have” data elements related to a patient visit

For More Information contact:

Dr. Carol DeFrances, ^{Branch Chief, Ambulatory and Hospital Care Statistics Branch}

^{301–458–4440 or cdefrances@cdc.gov}

Or visit the National Hospital Care Survey website: http://www.cdc.gov/nchs/nhcs.htm.

Data Elements extracted from your organization’s EHR or data repository

1. Needed data elements related to a patient visit:

1. Date of birth

2. Sex

3. Date of visit

4. Encounter number

5. All diagnoses including E codes and V codes

6. All reason(s) for visit and/or Chief Complaint

7. Vital signs (height, weight, blood pressure, temperature)

8. Provided or Ordered during the visit:

   • Diagnostic testing (e.g., lab, imaging, EKG, audiometry, biopsy)

   • Therapeutic procedures, including surgery, and non-medication treatments (e.g., physical therapy, speech therapy, home health care)

9. Results of testing or procedures provided or ordered during the visit, as many as are available

10. Disposition (Return appointment, Referred, Routine discharge (if surgery), Admitted to ED/hospital, etc.)

11. Most recent results and dates blood drawn for the following select lab tests:

    • Total cholesterol

    • HDL

    • LDL

    • Triglycerides

    • HbA1c

    • Blood glucose

    • Serum creatinine

12. Medications and immunizations

    • patient was taking at time of the visit and/or continued by provider during visit

    • supplied or administered during visit (including anesthesia and immunizations)

13. Active problems

2. PHI:

• Name

• Address including zip code

• SSN and Medicare number

• Patient’s medical record number

For More Information contact:

Dr. Carol DeFrances, ^{Branch Chief, Ambulatory and Hospital Care Statistics Branch}

^{301–458–4440 or cdefrances@cdc.gov}

Or visit the National Hospital Care Survey website: http://www.cdc.gov/nchs/nhcs.htm.

c. “Like to Have” data elements related to a patient visit IF they are readily obtainable:

• NPIs of physicians

• Race

• Ethnicity

• Source(s) of payment

• Type of clinic/location where visit occurred (family practice, cardiology, etc.)

• Has patient been seen in clinic/location before

  • If yes, how many visits in previous 12 months (excluding this visit)

• Is this provider the patient’s primary care provider or was patient referred for visit

• Is this visit for a new problem, chronic problem (routine or flare-up), pre-/post-surgery, preventive care

• Tobacco use

• If female is patient pregnant, and gestation week or last menstrual period

• If patient has asthma

  • Severity – (intermittent, mild persistent… severe persistent)

  • Control – (well controlled …very poorly controlled)

• Clinician notes (e.g., physicians’, nurses’, P.A.s’, N.P.s’ and C.N.M.s’ notes)

IF OUTPATIENT SURGERY or PROCEDURE PERFORMED

• Date and time for:

  • Into operating room and out of operating room

  • Surgery/Procedure began and ended

  • Into and out of postoperative care

• Provider(s) of anesthesia (e.g. anesthesiologist, CRNA, resident, surgeon)

• Symptom(s) present during or after surgery/procedure

• Any follow-up with patient within 24 hours and outcome

For More Information contact:

Dr. Carol DeFrances, ^{Branch Chief, Ambulatory and Hospital Care Statistics Branch}

^{301–458–4440 or cdefrances@cdc.gov}

Or visit the National Hospital Care Survey website: http://www.cdc.gov/nchs/nhcs.htm.

Page 5 of 5