Care Coordination

Participation in a systematic qualified clinical database registry involves:
a. Physician or other clinician submits standardized data elements to registry
b. Data elements are applicable to consensus endorsed quality measures
c. Registry measures shall include at least two (2) representative NQF consensus endorsed measures for registry's clinical topic(s) and report on all patients eligible for the selected measures.
d. Registry provides calculated measures results, benchmarking, and quality improvement information to individual physicians and clinicians.

Percentage of patients transferred to another HEALTHCARE FACILITY whose medical record documentation indicated that patient information was communicated to the receiving FACILITY within 60 minutes of departure

Percentage of patients transferred to another HEALTHCARE FACILITY whose medical record documentation indicated that physician information was communicated to the receiving FACILITY within 60 minutes of departure

Performance Measure Name: Procedures and Tests
Description: Patients who are transferred from an ED to another healthcare facility have communicated with the receiving facility within 60 minutes of discharge a list of tests done and results sent.

Documents the extent to which a provider uses certified/qualified electronic health record (EHR) system that incorporates an electronic data interchange with one or more laboratories allowing for direct electronic transmission of laboratory data into the EHR as discrete searchable data elements.

Percentage of home health episodes of care in which the start or resumption of care date was either on the physician-specified date or within 2 days of the referral date or inpatient discharge date, whichever is later.

Percentage of discharges from an inpatient facility (eg, hospital inpatient or observation, skilled nursing facility, or rehabilitation facility) to home or any other site of care, of patients, regardless of age, for which a transition record was transmitted to the facility or primary physician or other health care professional designated for follow-up care within 24 hours of discharge

Documentation of the extent to which a provider uses a certified/qualified electronic health record (EHR) system to track pending laboratory tests, diagnostic studies (including common preventive screenings) or patient referrals. The Electronic Health Record includes provider reminders when clinical results are not received within a predefined timeframe.

Percentage of discharges from an emergency department (ED) to ambulatory care or home health care, in which the patient, regardless of age, or their caregiver(s), received a transition record at the time of ED discharge including, at a minimum, all of the specified elements

Percentage of patients transferred to another HEALTHCARE FACILITY whose medical record documentation indicated that the entire vital signs record was communicated to the receiving FACILITY within 60 minutes of departure