ACCF/AHA 2011 Key Data Elements and Definitions of a Base Cardiovascular Vocabulary for Electronic Health Records: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Clinical Data Standards

Perspective:

The following are 10 points to remember about electronic health records (EHRs):

1. The purpose of clinical data standards is to contribute to the infrastructure necessary to accomplish the American College of Cardiology Foundation/American College of Cardiology mission of fostering optimal cardiovascular care and disease prevention and building healthier lives, free of cardiovascular diseases and stroke.

2. The tenets of meaningful use include the implementation and utilization of certified EHR solutions in a manner that promotes interoperable health information, improves the quality of health care and care coordination, and reports on quality measures.

3. Although patient age, sex, race, and ethnicity are key elements in various risk prediction models, these data elements are expected to be generically available in all EHR solutions and therefore have not been listed.

4. Information about the medical history and risk factors is key in appropriate use assessment, quality-performance measurement, clinical research, and clinical care.

5. Data elements include physician-classified symptom scales (e.g., New York Heart Association classification of functional class and Canadian Cardiovascular Society classification of anginal severity).

6. Chosen data elements for diagnostic and therapeutic cardiovascular procedures include those with specific value in representing a waypoint of care (e.g., procedure and date), in assessing process in delivery of quality care (e.g., appropriate use criteria assessment), that are predictive of outcome (e.g., key findings), or that identify implanted devices.

7. For therapeutic procedures, only key data elements facilitating clinical care are stressed. For example, for a percutaneous coronary intervention (PCI), in addition to the notation of PCI, the data to be handled as discrete data would include the date of the procedure, lesion treated, and stent-specific information.

8. The quantitative determination of systolic function occurs with substantial variability between modalities and with different reference ranges by modality. Nonetheless, this quantitative number is purposely included as a single (derived) data element irrespective of modality.

9. Pharmacological therapy data elements are central to many quality reporting initiatives and meaningful use, and are intended to capture whether or not the patient is currently receiving or is otherwise prescribed any member of the medication class in question in the context of the patient encounter.

10. The writing committee elected to focus on all-cause mortality and high-morbidity hospitalization outcomes likely to be captured and coded for administrative and billing purposes.

Clinical Topics: Invasive Cardiovascular Angiography and Intervention

Keywords: Electronic Health Records, Stroke, Vocabulary, Cardiology, Canada, New York, Hospitalization, United States, Stents, Percutaneous Coronary Intervention


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